Method of predicting risk of recurrence of cancer

ABSTRACT

A method for predicting risk of recurrence of cancer in an individual with cancer, the method comprising a step of assaying a cancer sample from the individual for positive expression of at least two genes or proteins encoded by those genes selected from the group consisting of FOXM1, UHRF1, PTTG1, E2F1, MYBL2, HMGB2, ATAD2, E2F8, ZNF367 and TCF19, wherein positive expression of the at least two genes correlates with increased risk of recurrence of cancer compared with an individual who does not exhibit positive expression of the at least two genes or proteins encoded by those genes.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application is a divisional under 35 U.S.C. § 121 of co-pendingU.S. application Ser. No. 15/511,890 filed Mar. 16, 2017, which is a 35U.S.C. § 371 National Phase Entry Application of InternationalApplication No. PCT/EP15/071524 filed Sep. 18, 2015, which designatesthe U.S. and claims benefit under 35 U.S.C. § 119(b) of EuropeanProvisional Application No. 14185673.2 filed Sep. 19, 2014, the contentsof which are incorporated herein by reference in their entireties.

SEQUENCE LISTING

The instant application contains a Sequence Listing which has beensubmitted in ASCII format via EFS-Web and is hereby incorporated byreference in its entirety. Said ASCII copy, created on Mar. 16, 2017, isnamed 11144PC00-Sequence-Listing-ST25.txt and is 8,349 bytes in size.

FIELD OF THE INVENTION

The invention relates to a method of predicting the risk of tumourrecurrence in a subject. Specifically, the invention relates to a methodof predicting the risk of early-stage node-negative breast cancer,prostate cancer and other tumour recurrence.

BACKGROUND TO THE INVENTION

Breast cancer is a heterogeneous disease which presents challenges forclinicians in predicting the likelihood of disease progression,particularly in patients where the disease is detected in the earlystages. For these women, the conventional clinico-pathologicalparameters (tumour size, lymph node status, patient age, tumour grade,and expression of biomarkers including Estrogen Receptor (ER),Progesterone Receptor (PR), Human Epidermal growth factor Receptor 2(Her2), Ki67) are not sufficient to characterise disease complexity andaccurately predict the likelihood of tumour recurrence followingadjuvant treatment or tumour removal by surgery. Therefore, due toinaccurate risk stratification, many of these patients who areinherently at a low risk of recurrence are assigned to receivechemotherapy, when in fact the majority of these women would remaincancer-free even without this toxic treatment.

In fact, it is estimated that, for node-negative, ER-positive disease,up to 85% of patients would be overtreated if given chemotherapy (Fisheret al., 2004). Furthermore, surviving patients treated with chemotherapyface a higher risk of developing a second, independent, primary cancerin unrelated tissues within their lifetime (Boffetta and Kaldor, 1994).Considering the severe side-effects, the public health burden and thefuture health implications of chemotherapy, the overtreatment ofpatients represents a major problem in the clinical management ofearly-stage breast cancer.

The challenge is to develop a method of accurately and reproduciblydistinguishing the low-risk from the high-risk patients so that therapycan be assigned accordingly. Current guidelines often lead to differingopinions from breast oncologists as to whether to assign neoadjuvantand/or adjuvant therapy, as many are reluctant to forego neoadjuvantand/or adjuvant therapy without a reliable assessment of recurrencerisk. The addition of more accurate and reliable prognostic andpredictive biomarkers to the standard clinical assessment would greatlyimprove the ability of both doctors and patients to make morewell-informed treatment decisions. Some progress is being made in thisregard with the multigene assays Oncotype Dx® Breast Cancer Assay andMammaPrint™, which are currently being assessed in the Trial AssigningIndividuaLized Options for Treatment (Rx) (TAILORx) and Microarray InNode-negative and 1 to 3 positive lymph node Disease may AvoidChemoTherapy (MINDACT) trials, respectively (Cardoso et al., 2008;Sparano, 2006). MammaPrint™ and Prosigna™ are examples of Food and DrugAgency-approved prognostic tests in this arena.

WO 2005/039382 describes a number of gene sets used in predicting thelikelihood of breast cancer recurrence, otherwise known as Oncotype Dx®referred to above. The invention is related to a gene set comprising‘one or more’ genes from a panel of 50 genes. WO 2104/130825 describes agene set comprising least 4 genes from a panel of cell cycle genes fordetecting risk of lung cancer. U.S. Pat. No. 7,914,988 describes a geneexpression signature to predict relapse in prostate cancer, known as theGEX score. The invention is related to a gene set comprising ‘all or asub-combination of’ genes from a panel of 21 genes.

The widespread use of gene expression profiling has led to a rapidexpansion in the identification of gene expression signatures found tocorrelate with different aspects of tumour progression. These includethe ‘poor prognosis’(van de Vijver et al., 2002; Wang et al., 2005),‘invasiveness’ (Liu et al., 2007), and ‘genomic grade’ (Sotiriou et al.,2006) signatures. US 2008/275652 describes how this genomic gradesignature comprises at least 2 or 4 genes selected from a panel of 97genes. However, despite the ability of these signatures to predictbreast cancer prognosis, there is surprisingly little overlap betweensignatures. The Applicants suggest that many genes in these signaturesmay be ‘passengers’, rather than ‘drivers’ of tumour progression. Recentadvances in genome-wide reverse engineering have made it possible tosuccessfully identify regulatory interactions between transcriptionfactors and downstream genes which were causal rather than correlative(Carro et al., 2010). One such algorithm, the Algorithm for theReconstruction of Accurate Cellular Networks (ARACNe) (Margolin et al.,2006), uses gene interaction networks constructed from transcriptomicdatasets to identify ‘hubs’, usually transcription factors, which arepredicted to directly regulate multiple genes in the signature.

It is an object of the present invention to overcome at least one of theabove-mentioned problems.

SUMMARY OF THE INVENTION

Predicting the risk of tumour recurrence, and thus the need for adjuvanttherapy, for lymph node negative breast cancer patients (and earlystage, node positive breast cancer) can be a significant problem forclinicians and patients. A ‘core proliferation signature’ has beenidentified herein which is consistently high in proliferating primarycultures, and is downregulated during cellular senescence. This genesignature is also highly expressed in aggressive breast cancers. Ahierarchy of several Master Transcriptional Regulators(MTRs—transcription factors responsible for the regulation of this coreset of genes) upstream of these core proliferation genes has beenidentified. Further analysis of the expression of these factors inbreast cancer datasets at the mRNA and protein levels reveals aremarkable ability to predict recurrence risk for early-stage breastcancer. Strikingly, combining two of these factors outperforms thecurrently used clinical biomarkers for breast cancer recurrence risk, aswell as recently developed multi-gene prognostic assays such as OncotypeDx®. The addition of the senescence regulator p16^(INK4A) to theprognostic panel of proliferative factors allows the identification oftumours with a disrupted cellular senescence pathway, further improvingthe prognostic power of the invention. Furthermore, unbiased survivalanalysis of several breast cancer datasets has revealed genes involvedin alternative breast cancer-associated pathways such asapoptosis-resistance, invasion and immune response, which can becombined with the MTR panel to increase the prognostic power evenfurther. This approach devised by the Applicant has succeeded inidentifying ‘drivers’ of cancer proliferation which, when combined withadditional biomarkers, has the potential to become a superior prognosticassay for early-stage cancer. Thus, by identifying the upstream‘drivers’ or regulators of key signatures, more accurate and reliablepredictors of breast cancer prognosis can be identified. The Applicanthas called this ‘core proliferation signature’ OncoMasTR, and this namewill be used herein.

According to the invention, there is provided a method for predictingrisk of recurrence of cancer in an individual with cancer, the methodcomprising a step of assaying a cancer sample from the individual forpositive expression of at least two genes (or proteins encoded by thosegenes) selected from the group consisting of FOXM1, UHRF1, PTTG1, E2F1,MYBL2, HMGB2, ATAD2, E2F8, ZNF367 and TCF19, wherein positive expressionof at least two genes, or proteins encoded by said genes, correlateswith increased risk of recurrence of cancer compared with an individualwith cancer who does not exhibit positive expression of the same genes.

According to the invention, there is provided a method of predictingrisk of recurrence of cancer in an individual with cancer followingtreatment with CDK4/6 inhibitors, the method comprising a step ofassaying a cancer sample from the individual for positive expression ofat least two genes, or proteins encoded by said genes, selected from thegroup consisting of FOXM1, UHRF1, PTTG1, E2F1, MYBL2,HMGB2, ATAD2, E2F8,ZNF367 and TCF19, wherein positive expression of the at least two genes,or proteins encoded by said genes, correlates with increased risk ofrecurrence of cancer in an individual with cancer following treatmentwith CDK4/6 inhibitors compared with an individual with cancer who doesnot exhibit positive expression of the at least two genes or proteinsencoded by those genes.

According to the invention, there is provided a method of determining a5-year survival rate or a 10-year survival rate of an individualdiagnosed with breast cancer, the method comprising a step of assaying acancer tumour sample from the individual for positive expression of atleast two genes, or proteins encoded by those genes, selected fromFOXM1, UHRF1, PTTG1, E2F1, MYBL2, HMGB2, ATAD2, E2F8, ZNF367 and TCF19,wherein positive expression of the at least two genes, or proteinsencoded by those genes, correlates with decreased chance of 5-yearsurvival rate or a 10-year survival rate compared with an individualwith cancer who does not exhibit positive expression of the at least twogenes or proteins encoded by those genes.

In one embodiment, the method further comprises the step of assaying forthe expression of the p16^(INK4A) gene or protein in addition to the atleast two genes (or proteins) selected from the group consisting ofFOXM1, UHRF1, PTTG1, E2F1, MYBL2, HMGB2, ATAD2, E2F8, ZNF367 and TCF19,wherein dysregulated expression of p16^(INK4A) in combination withpositive expression of the at least two genes (or proteins encoded bythose genes) selected from the group consisting of FOXM1, UHRF1, PTTG1,E2F1, MYBL2, HMGB2, ATAD2, E2F8, ZNF367 and TCF19, correlates withincreased risk of recurrence of cancer, or a decreased chance of a5-year survival rate or a 10-year survival rate, compared with anindividual with cancer who does not exhibit dysregulated expression ofp16^(INK4A) and positive expression of the at least two genes (orproteins encoded by those genes). Breast cancer patients withdysregulated expression of p16^(INK4A) and positive expression of the atleast two genes (or proteins encoded by those genes) have an increasedrisk of recurrence of cancer, or a decreased chance of a 5-year survivalrate or a 10-year survival rate, compared with patients with cancer thatdo not exhibit the expression pattern of this combination of genes (orproteins encoded by those genes).

In one embodiment, the at least two genes selected are FOXM1 and UHRF1.In one embodiment, the at least two genes selected are FOXM1 and PTTG1.In one embodiment, the at least two genes selected are FOXM1 and E2F1.In one embodiment, the at least two genes selected are FOXM1 and MYBL2.In one embodiment, the at least two genes selected are FOXM1 and HMGB2.In one embodiment, the at least two genes selected are UHRF1 and PTTG1.In one embodiment, the at least two genes selected are UHRF1 and E2F1.In one embodiment, the at least two genes selected are UHRF1 and MYBL2.In one embodiment, the at least two genes selected are UHRF1 and HMGB2.In one embodiment, the at least two genes selected are PTTG1 and E2F1.In one embodiment, the at least two genes selected are PTTG1 and MYBL2.In one embodiment, the at least two genes selected are PTTG1 and HMGB2.In one embodiment, the at least two genes selected are E2F1 and MYBL2.In one embodiment, the at least two genes selected are E2F1 and HMGB2.In one embodiment, the at least two genes selected are MYBL2 and HMGB2.In one embodiment, the at least two genes selected are FOXM1 and ATAD2.In one embodiment, the at least two genes selected are FOXM1 and E2F8.In one embodiment, the at least two genes selected are FOXM1 and ZNF367.In one embodiment, the at least two genes selected are FOXM1 and TCF19.In one embodiment, the at least two genes selected are UHRF1 and ATAD2.In one embodiment, the at least two genes selected are UHRF1 and E2F8.In one embodiment, the at least two genes selected are UHRF1 and ZNF367.In one embodiment, the at least two genes selected are UHRF1 and TCF19.In one embodiment, the at least two genes selected are PTTG1 and ATAD2.In one embodiment, the at least two genes selected are PTTG1 and E2F8.In one embodiment, the at least two genes selected are PTTG1 and ZNF367.In one embodiment, the at least two genes selected are PTTG1 and TCF19.In one embodiment, the at least two genes selected are E2F1 and ATAD2.In one embodiment, the at least two genes selected are E2F1 and E2F8. Inone embodiment, the at least two genes selected are E2F1 and ZNF367. Inone embodiment, the at least two genes selected are E2F1 and TCF19. Inone embodiment, the at least two genes selected are MYBL2 and ATAD2. Inone embodiment, the at least two genes selected are MYBL2 and E2F8. Inone embodiment, the at least two genes selected are MYBL2 and ZNF367. Inone embodiment, the at least two genes selected are MYBL2 and TCF19. Inone embodiment, the at least two genes selected are HMGB2 and ATAD2. Inone embodiment, the at least two genes selected are HMGB2 and E2F8. Inone embodiment, the at least two genes selected are HMGB2 and ZNF367. Inone embodiment, the at least two genes selected are HMGB2 and TCF19. Inone embodiment, the at least two genes selected are E2F8 and ATAD2. Inone embodiment, the at least two genes selected are E2F8 and TCF19. Inone embodiment, the at least two genes selected are E2F8 and ZNF367. Inone embodiment, the at least two genes selected are ZNF367 and ATAD2. Inone embodiment, the at least two genes selected are ZNF367 and TCF19. Inone embodiment, the at least two genes selected are TCF19 and ATAD2.Preferably, the at least two genes selected above are combined withp16^(INK4A).

In one embodiment, at least three genes are selected and the genesselected are FOXM1, UHRF1 and PTTG1. In one embodiment, the genesselected are FOXM1, UHRF1 and E2F1. In one embodiment, the genesselected are FOXM1, UHRF1 and MYBL2. In one embodiment, the genesselected are FOXM1, UHRF1 and HMGB2. In one embodiment, the genesselected are FOXM1, PTTG1 and E2F1. In one embodiment, the genesselected are FOXM1, PTTG1 and MYBL2. In one embodiment, the genesselected are FOXM1, PTTG1 and HMGB2. In one embodiment, the genesselected are FOXM1, E2F1 and MYBL2. In one embodiment, the genesselected are FOXM1, E2F1 and HMGB2. In one embodiment, the genesselected are FOXM1, MYBL2 and HMGB2. In one embodiment, the genesselected are UHRF1, PTTG1 and E2F1. In one embodiment, the genesselected are UHRF1, PTTG1 and MYBL2. In one embodiment, the genesselected are UHRF1, PTTG1 and HMGB2. In one embodiment, the genesselected are PTTG1, E2F1 and MYBL2. In one embodiment, the genesselected are PTTG1, E2F1 and HMGB2. In one embodiment, the genesselected are E2F1, MYBL2 and HMGB2. In one embodiment, the genesselected are FOXM1, UHRF1 and ATAD2. In one embodiment, the genesselected are FOXM1, UHRF1 and E2F8. In one embodiment, the genesselected are FOXM1, UHRF1 and ZNF67. In one embodiment, the genesselected are FOXM1, UHRF1 and TCF19. In one embodiment, the genesselected are FOXM1, PTTG1 and ATAD2. In one embodiment, the genesselected are FOXM1, PTTG1 and E2F8. In one embodiment, the genesselected are FOXM1, PTTG1 and ZNF367. In one embodiment, the genesselected are FOXM1, PTTG1 and TCF19. In one embodiment, the genesselected are FOXM1, E2F1 and ATAD2. In one embodiment, the genesselected are FOXM1, E2F1 and E2F8. In one embodiment, the genes selectedare FOXM1, E2F1 and ZNF367. In one embodiment, the genes selected areFOXM1, E2F1 and TCF19. In one embodiment, the genes selected are FOXM1,MYBL2 and ATAD2. In one embodiment, the genes selected are FOXM1, MYBL2and E2F8. In one embodiment, the genes selected are FOXM1, MYBL2 andZNF367. In one embodiment, the genes selected are FOXM1, MYBL2 andTCF19. In one embodiment, the genes selected are UHRF1, PTTG1 and ATAD2.In one embodiment, the genes selected are UHRF1, PTTG1 and E2F8. In oneembodiment, the genes selected are UHRF1, PTTG1 and ZNF367. In oneembodiment, the genes selected are UHRF1, PTTG1 and TCF19. In oneembodiment, the genes selected are PTTG1, E2F1 and ATAD2. In oneembodiment, the genes selected are PTTG1, E2F1 and E2F8. In oneembodiment, the genes selected are PTTG1, E2F1 and ZNF367. In oneembodiment, the genes selected are PTTG1, E2F1 and TCF19. In oneembodiment, the genes selected are E2F1, MYBL2 and ATAD2. In oneembodiment, the genes selected are E2F1, MYBL2 and E2F8. In oneembodiment, the genes selected are E2F1, MYBL2 and ZNF367. In oneembodiment, the genes selected are E2F1, MYBL2 and TCF19. In oneembodiment, the genes selected are FOXM1, HMGB2 and ATAD2. In oneembodiment, the genes selected are FOXM1, HMGB2 and E2F8. In oneembodiment, the genes selected are FOXM1, HMGB2 and ZNF67. In oneembodiment, the genes selected are FOXM1, HMGB2 and TCF19. In oneembodiment, the genes selected are HMGB2, PTTG1 and ATAD2. In oneembodiment, the genes selected are HMGB2, PTTG1 and E2F8. In oneembodiment, the genes selected are HMGB2, PTTG1 and ZNF367. In oneembodiment, the genes selected are HMGB2, PTTG1 and TCF19. In oneembodiment, the genes selected are HMGB2, E2F1 and ATAD2. In oneembodiment, the genes selected are HMGB2, E2F1 and E2F8. In oneembodiment, the genes selected are HMGB2, E2F1 and ZNF367. In oneembodiment, the genes selected are HMGB2, E2F1 and TCF19. In oneembodiment, the genes selected are HMGB2, MYBL2 and ATAD2. In oneembodiment, the genes selected are HMGB2, MYBL2 and E2F8. In oneembodiment, the genes selected are HMGB2, MYBL2 and ZNF367. In oneembodiment, the genes selected are HMGB2, MYBL2 and TCF19. In oneembodiment, the genes selected are UHRF1, HMGB2 and ATAD2. In oneembodiment, the genes selected are UHRF1, HMGB2 and E2F8. In oneembodiment, the genes selected are UHRF1, HMGB2 and ZNF367. In oneembodiment, the genes selected are UHRF1, HMGB2 and TCF19. In oneembodiment, the genes selected are E2F8, ZNF367 and ATAD2. In oneembodiment, the genes selected are E2F8, ZNF367 and TCF19. In oneembodiment, the genes selected are ATAD2, E2F8 and TCF19. Preferably,the at least three genes selected above are combined with p16^(INK4A).

In one embodiment, at least four genes are selected and the genesselected are FOXM1, UHRF1, PTTG1 and E2F1. In one embodiment, the genesselected are FOXM1, UHRF1, PTTG1 and MYBL2. In one embodiment, the genesselected are FOXM1, UHRF1, PTTG1 and HMGB2. In one embodiment, the genesselected are FOXM1, UHRF1, E2F1 and MYBL2. In one embodiment, the genesselected are FOXM1, UHRF1, E2F1 and HMGB2. In one embodiment, the genesselected are FOXM1, UHRF1, MYBL2 and HMGB2. In one embodiment, the genesselected are FOXM1, PTTG1, E2F1 and MYBL2. In one embodiment, the genesselected are FOXM1, PTTG1, E2F1 and HMGB2. In one embodiment, the genesselected are FOXM1, E2F1, MYBL2 and HMGB2. In one embodiment, the genesselected are UHRF1, PTTG1, E2F1 and MYBL2. In one embodiment, the genesselected are UHRF1, PTTG1, E2F1 and HMGB2. In one embodiment, the genesselected are PTTG1, E2F1, MYBL2 and HMGB2. In one embodiment, the genesselected are FOXM1, UHRF1, PTTG1 and ATAD2. In one embodiment, the genesselected are FOXM1, UHRF1, PTTG1 and E2F8. In one embodiment, the genesselected are FOXM1, UHRF1, PTTG1 and ZNF367. In one embodiment, thegenes selected are FOXM1, UHRF1, PTTG1 and TCF19. In one embodiment, thegenes selected are FOXM1, UHRF1, E2F1 and ATAD2. In one embodiment, thegenes selected are FOXM1, UHRF1, E2F1 and E2F8. In one embodiment, thegenes selected are FOXM1, UHRF1, E2F1 and ZNF367. In one embodiment, thegenes selected are FOXM1, UHRF1, E2F1 and TCF19. In one embodiment, thegenes selected are FOXM1, UHRF1, MYBL2 and ATAD2. In one embodiment, thegenes selected are FOXM1, UHRF1, MYBL2 and E2F8. In one embodiment, thegenes selected are FOXM1, UHRF1, MYBL2 and ZNF367. In one embodiment,the genes selected are FOXM1, UHRF1, MYBL2 and TCD1. In one embodiment,the genes selected are FOXM1, UHRF1, HMGB2 and ATAD2. In one embodiment,the genes selected are FOXM1, UHRF1, HMGB2 and E2F8. In one embodiment,the genes selected are FOXM1, UHRF1, HMGB2 and ZNF37. In one embodiment,the genes selected are FOXM1, UHRF1, HMGB2 and TCF19. In one embodiment,the genes selected are FOXM1, PTTG1, E2F1 and ATAD2. In one embodiment,the genes selected are FOXM1, PTTG1, E2F1 and E2F8. In one embodiment,the genes selected are FOXM1, PTTG1, E2F1 and ZNF367. In one embodiment,the genes selected are FOXM1, PTTG1, E2F1 and TCF19. In one embodiment,the genes selected are FOXM1, PTTG1, MYBL2 and ATAD2. In one embodiment,the genes selected are FOXM1, PTTG1, MYBL2 and E2F8. In one embodiment,the genes selected are FOXM1, PTTG1, MYBL2 and ZNF367. In oneembodiment, the genes selected are FOXM1, PTTG1, MYBL2 and TCF19. In oneembodiment, the genes selected are FOXM1, PTTG1, HMGB2 and ATAD2. In oneembodiment, the genes selected are FOXM1, PTTG1, HMGB2 and E2F8. In oneembodiment, the genes selected are FOXM1, PTTG1, HMGB2 and ZNF367. Inone embodiment, the genes selected are FOXM1, PTTG1, HMGB2 and TCF19. Inone embodiment, the genes selected are FOXM1, E2F1, MYBL2 and ATAD2. Inone embodiment, the genes selected are FOXM1, E2F1, MYBL2 and E2F8. Inone embodiment, the genes selected are FOXM1, E2F1, MYBL2 and ZNF367. Inone embodiment, the genes selected are FOXM1, E2F1, MYBL2 and TCF19. Inone embodiment, the genes selected are FOXM1, E2F1, HMGB2 and ATAD2. Inone embodiment, the genes selected are FOXM1, E2F1, HMGB2 and E2F8. Inone embodiment, the genes selected are FOXM1, E2F1, HMGB2 and ZNF367. Inone embodiment, the genes selected are FOXM1, E2F1, HMGB2 and TCF19. Inone embodiment, the genes selected are FOXM1, MYBL2, HMGB2 and ATAD2. Inone embodiment, the genes selected are FOXM1, MYBL2, HMGB2 and E2F8. Inone embodiment, the genes selected are FOXM1, MYBL2, HMGB2 and ZNF367.In one embodiment, the genes selected are FOXM1, MYBL2, HMGB2 and TCF19.In one embodiment, the genes selected are UHRF1, PTTG1, E2F1 and ATAD2.In one embodiment, the genes selected are UHRF1, PTTG1, E2F1 and E2F8.In one embodiment, the genes selected are UHRF1, PTTG1, E2F1 and ZNF367.In one embodiment, the genes selected are UHRF1, PTTG1, E2F1 and TCF19.In one embodiment, the genes selected are UHRF1, PTTG1, MYBL2 and ATAD2.In one embodiment, the genes selected are UHRF1, PTTG1, MYBL2 and E2F8.In one embodiment, the genes selected are UHRF1, PTTG1, MYBL2 and ZNF36.In one embodiment, the genes selected are UHRF1, PTTG1, MYBL2 and TCF19.In one embodiment, the genes selected are UHRF1, PTTG1, HMGB2 and ATAD2.In one embodiment, the genes selected are UHRF1, PTTG1, HMGB2 and E2F8.In one embodiment, the genes selected are UHRF1, PTTG1, HMGB2 andZNF367. In one embodiment, the genes selected are UHRF1, PTTG1, HMGB2and TCF19. In one embodiment, the genes selected are PTTG1, E2F1, MYBL2and ATAD2. In one embodiment, the genes selected are PTTG1, E2F1, MYBL2and E2F8. In one embodiment, the genes selected are PTTG1, E2F1, MYBL2and ZNF367. In one embodiment, the genes selected are PTTG1, E2F1, MYBL2and TCF19. In one embodiment, the genes selected are PTTG1, E2F1, HMGB2and ATAD2. In one embodiment, the genes selected are PTTG1, E2F1, HMGB2and E2F8. In one embodiment, the genes selected are PTTG1, E2F1, HMGB2and ZNF367. In one embodiment, the genes selected are PTTG1, E2F1, HMGB2and TCF19. In one embodiment, the genes selected are E2F1, MYBL2, HMGB2and ATAD2. In one embodiment, the genes selected are E2F1, MYBL2, HMGB2and E2F8. In one embodiment, the genes selected are E2F1, MYBL2, HMGB2and ZNF367. In one embodiment, the genes selected are E2F1, MYBL2, HMGB2and TCF19. In one embodiment, the genes selected are ATAD2, EDF8, ZNF367and TCF19. Preferably, the at least four genes selected above arecombined with p16^(INK4A).

In one embodiment, at least five genes are selected and the genesselected are FOXM1, UHRF1, PTTG1, E2F1 and MYBL2. In one embodiment, thegenes selected are FOXM1, UHRF1, PTTG1, E2F1 and HMGB2. In oneembodiment, the genes selected are FOXM1, PTTG1, E2F1, MYBL2 and HMGB2.In one embodiment, the genes selected are UHRF1, PTTG1, E2F1, MYBL2 andHMGB2. In one embodiment, the genes selected are FOXM1, UHRF1, PTTG1,E2F1 and ATAD2. In one embodiment, the genes selected are FOXM1, UHRF1,PTTG1, E2F1 and E2F8. In one embodiment, the genes selected are FOXM1,UHRF1, PTTG1, E2F1 and ZNF367. In one embodiment, the genes selected areFOXM1, UHRF1, PTTG1, E2F1 and TCF19. In one embodiment, the genesselected are FOXM1, UHRF1, PTTG1, MYBL2 and ATAD2. In one embodiment,the genes selected are FOXM1, UHRF1, PTTG1, MYBL2 and EFF8. In oneembodiment, the genes selected are FOXM1, UHRF1, PTTG1, MYBL2 andZNF367. In one embodiment, the genes selected are FOXM1, UHRF1, PTTG1,MYBL2 and TCF19. In one embodiment, the genes selected are FOXM1, UHRF1,PTTG1, HMGB2 and ATAD2. In one embodiment, the genes selected are FOXM1,UHRF1, PTTG1, HMGB2 and E2F8. In one embodiment, the genes selected areFOXM1, UHRF1, PTTG1, HMGB2 and ZNF367. In one embodiment, the genesselected are FOXM1, UHRF1, PTTG1, HMGB2 and TCF19. In one embodiment,the genes selected are UHRF1, PTTG1, E2F1, MYBL2 and ATAD2. In oneembodiment, the genes selected are UHRF1, PTTG1, E2F1, MYBL2 and E2F8.In one embodiment, the genes selected are UHRF1, PTTG1, E2F1, MYBL2 andZNF367. In one embodiment, the genes selected are UHRF1, PTTG1, E2F1,MYBL2 and TCF19. In one embodiment, the genes selected are UHRF1, PTTG1,E2F1, HMBG2 and ATAD2. In one embodiment, the genes selected are UHRF1,PTTG1, E2F1, HMBG2 and E2F8. In one embodiment, the genes selected areUHRF1, PTTG1, E2F1, HMBG2 and ZNF367. In one embodiment, the genesselected are UHRF1, PTTG1, E2F1, HMBG2 and TCF19. In one embodiment, thegenes selected are PTTG1, E2F1, MYBL2, HMGB2 and ATAD2. In oneembodiment, the genes selected are PTTG1, E2F1, MYBL2, HMGB2 and E2F8.In one embodiment, the genes selected are PTTG1, E2F1, MYBL2, HMGB2 andZNF367. In one embodiment, the genes selected are PTTG1, E2F1, MYBL2,HMGB2 and TCF19. In one embodiment, the genes selected are ATAD2, E2F8,ZNF367, TCF19 and FOXM1. In one embodiment, the genes selected areATAD2, E2F8, ZNF367, TCF19 and UHRF1. In one embodiment, the genesselected are ATAD2, E2F8, ZNF367, TCF19 and PTTG1. In one embodiment,the genes selected are ATAD2, E2F8, ZNF367, TCF19 and E2F1. In oneembodiment, the genes selected are ATAD2, E2F8, ZNF367, TCF19 and MYBL2.In one embodiment, the genes selected are ATAD2, E2F8, ZNF367, TCF19 andHMGB2. Preferably, the at least five genes selected above are combinedwith p16^(INK4A).

In one embodiment, the at least two genes comprise FOXM1, and at leastone further gene selected from UHRF1, PTTG1, E2F1, MYBL2, HMGB2, ATAD2,E2F8, ZNF367 and TCF19. Preferably, the at least two genes is furthercombined with p16^(INK4A).

In one embodiment, the at least two genes comprise UHRF1, and at leastone further gene selected from FOXM1, PTTG1, E2F1, MYBL2, HMGB2, ATAD2,E2F8, ZNF367 and TCF19. Preferably, the at least two genes is furthercombined with p16^(INK4A).

In one embodiment, the at least two genes comprise PTTG1, and at leastone further gene selected from FOXM1, UHRF1, E2F1, MYBL2, HMGB2, ATAD2,E2F8, ZNF367 and TCF19. Preferably, the at least two genes is furthercombined with p16^(INK4A).

In one embodiment, the at least two genes comprise E2F1, and at leastone further gene selected from FOXM1, PTTG1, UHRF1, MYBL2, HMGB2, ATAD2,E2F8, ZNF367 and TCF19. Preferably, the at least two genes is furthercombined with p16^(INK4A).

In one embodiment, the at least two genes comprise MYBL2, and at leastone further gene selected from FOXM1, PTTG1, E2F1, UHRF1, HMGB2, ATAD2,E2F8, ZNF367 and TCF19. Preferably, the at least two genes is furthercombined with p16^(INK4A).

In one embodiment, the at least two genes comprise HMGB2, and at leastone further gene selected from FOXM1, PTTG1, E2F1, MYBL2, UHRF1, ATAD2,E2F8, ZNF367 and TCF19. Preferably, the at least two genes is furthercombined with p16^(INK4A).

In one embodiment, the genes selected are FOXM1, UHRF1, PTTG1, E2F1,MYBL2 and HMGB2. Preferably, the genes selected are further combinedwith p16^(INK4A).

In one embodiment, the genes selected are FOXM1, UHRF1, PTTG1, E2F1,MYBL2, HMGB2, and one or more or all of ATAD2, E2F8, ZNF367 and TCF19.Preferably, the genes selected are further combined with p16^(INK4A).

In one embodiment, the genes selected consist essentially of FOXM1,UHRF1, PTTG1, E2F1, MYBL2, and HMGB2. Preferably, the genes are furthercombined with p16^(INK4A). The term “consist essentially of” should beunderstood to mean all six genes, or five genes, or four genes, or threegenes, or two genes selected from FOXM1, UHRF1, PTTG1, E2F1, MYBL2, andHMGB2.

In one embodiment, the cancer is selected from the group comprisingnode-negative, ER-positive breast cancer; early stage, node positivebreast cancer; multiple myeloma, prostate cancer, glioblastoma,lymphoma, fibrosarcoma; myxosarcoma; liposarcoma; chondrosarcoma;osteogenic sarcoma; chordoma; angiosarcoma; endotheliosarcoma;lymphangiosarcoma; lymphangioendotheliosarcoma; synovioma; mesothelioma;Ewing's tumour; leiomyosarcoma; rhabdomyosarcoma; colon carcinoma;pancreatic cancer; breast cancer; ovarian cancer; squamous cellcarcinoma; basal cell carcinoma; adenocarcinoma; sweat gland carcinoma;sebaceous gland carcinoma; papillary carcinoma; papillaryadenocarcinomas; cystadenocarcinoma; medullary carcinoma; bronchogeniccarcinoma; renal cell carcinoma; hepatoma; bile duct carcinoma;choriocarcinoma; seminoma; embryonal carcinoma; Wilms' tumour; cervicalcancer; uterine cancer; testicular tumour; lung carcinoma; small celllung carcinoma; bladder carcinoma; epithelial carcinoma; glioma;astrocytoma; medulloblastoma; craniopharyngioma; ependymoma; pinealoma;hemangioblastoma; acoustic neuroma; oligodendroglioma; meningioma;melanoma; retinoblastoma; and leukemias. Suitably, the cancer is anepithelial cancer.

In one embodiment, the cancer is preferably breast cancer or prostatecancer. Ideally, the breast cancer is early stage, typicallynode-negative breast cancer or early stage, node positive breast cancer.Ideally, the breast cancer is early stage, node-negative or early stage,node positive, ER-positive breast cancer.

In one embodiment, the recurrence is development of a secondary tumour.

In one embodiment, the recurrence is developing a further, independentprimary cancer unrelated to the sampled cancer.

In one embodiment of the invention, there is provided a method ofpredicting the risk of recurrence of breast cancer in an early stage,node-negative breast cancer patient, or an early stage, node positivebreast cancer patient, the method comprising a step of assaying a cancertumour sample from the breast cancer patient for positive expression ofat least two genes (or proteins encoded by those genes) selected fromthe group consisting of FOXM1, UHRF1, PTTG1, E2F1, MYBL2, HMGB2, ATAD2,E2F8, ZNF367, and TCF19, wherein positive expression of the at least twogenes (or proteins encoded by those genes) correlates with increasedrisk of recurrence of cancer compared with an individual with cancer whodoes not exhibit positive expression of the at least two genes (orproteins encoded by those genes).

In one embodiment, the method further comprises the step of assaying forthe expression of the p16^(INK4A) gene (or a protein encoded by saidgene) in addition to the at least two genes (or proteins encoded bythose genes) selected from the group consisting of FOXM1, UHRF1, PTTG1,E2F1, MYBL2, HMGB2, ATAD2, E2F8, ZNF367 and TCF19, wherein dysregulatedexpression of p16^(INK4A) in combination with positive expression of acombination of the at least two of genes (or proteins encoded by thosegenes), correlates with increased risk of recurrence of cancer comparedwith an individual with cancer who does not exhibit dysregulatedexpression of p16^(INK4A) and positive expression of the at least twogenes (or proteins encoded by those genes). Breast cancer patients withdysregulated p16^(INK4A) and positive expression of the at least twogenes (or proteins encoded by those genes) have an increased risk ofrecurrence of cancer compared with individuals with cancer that do notexhibit the combination of positive expression of the at last two genesand dysregulated expression of p16^(INK4A).

In one embodiment of the invention, there is provided a method ofidentifying a cancer patient that is suitable for treatment with atherapy for preventing recurrence or progression of the cancer, themethod comprising a step of assaying a cancer sample from the cancerpatient for positive expression of at least two genes (or proteinsencoded by those genes) selected from the group consisting of FOXM1,UHRF1, PTTG1, E2F1, MYBL2, HMGB2, ATAD2, E2F8, ZNF367 and TCF19, whereinpositive expression of the at least two genes (or proteins encoded bythose genes) compared with an individual with cancer who does notexhibit positive expression of the at least two genes (or proteinsencoded by those genes), is indicative that the cancer patient issuitable for treatment with a therapy for preventing recurrence orprogression of the cancer.

In one embodiment, the therapy is a neoadjuvant therapy. In thespecification, the term “neoadjuvant therapy” should be understood tomean treatment given before primary treatment to increase the chances oflong-term survival. Primary treatment is generally surgery. Neoadjuvanttherapy are generally selected from chemotherapy, hormonal therapy,targeted therapy, radiation therapy, immunotherapy or a combinationthereof.

In one embodiment, the therapy is an adjuvant therapy. In thespecification, the term “adjuvant therapy” should be understood to meanany treatment given after primary treatment to increase the chances oflong-term survival. Primary treatment is generally surgery. Adjuvanttherapy are generally selected from chemotherapy, hormonal therapy,targeted therapy, radiation therapy, immunotherapy or a combinationthereof.

In one embodiment, the therapy can be a combination of neoadjuvant andadjuvant therapy. It should be understood that in the specification, the“neoadjuvant” and “adjuvant” therapies can be used interchangeably.

In one embodiment, the method further comprises the step of assaying forthe expression of the p16^(INK4A) gene (or a protein encoded by saidgene) in addition to the at least two genes (or proteins encoded bythose genes) selected from the group consisting of FOXM1, UHRF1, PTTG1,E2F1, MYBL2, HMGB2, ATAD2, E2F8, ZNF367 and TCF19, wherein dysregulatedexpression of p16^(INK4A) in combination with positive expression of acombination of at least two of the genes (or proteins encoded by thosegenes), when compared with an individual with cancer who does notexhibit dysregulated expression of p16^(INK4A) and positive expressionof the at least two genes, is indicative that the cancer patient issuitable for treatment with an adjuvant therapy for preventingrecurrence or progression of the cancer. Breast cancer patients withdysregulated p16^(INK4A) expression and positive expression of the atleast two genes (or proteins encoded by those genes) may be suitable fortreatment with an adjuvant therapy for preventing recurrence orprogression of the cancer.

In one embodiment, the cancer patient may be suitable for treatment witha neoadjuvant therapy for preventing recurrence or progression of thecancer.

In one embodiment, the cancer is early stage, node-negative breastcancer or early stage, node positive breast cancer. Ideally, breastcancer is early stage, node-negative, ER-positive breast cancer or earlystage, node positive, ER-positive breast cancer.

In one embodiment, the adjuvant therapy and neoadjuvant therapy ischemotherapeutic therapy. In one embodiment, the adjuvant therapy andneoadjuvant therapy is a CDK4/6 inhibitor therapy such as palbociclibtherapy (PD 0332991, Pfizer), Abemaciclib (LY2835219; Lilly, USA), orLEE011 (Novartis, Switzerland).

In one embodiment of the invention, there is provided a system forobtaining data from at least one test sample obtained from at least oneindividual, the system comprising:

-   -   a determination module configured to receive at least one test        sample and perform at least one test analysis on the test sample        to assay for expression of at least two genes (or proteins        encoded by those genes) selected from the group consisting of        FOXM1, UHRF1, PTTG1, E2F1, MYBL2, HMGB2, ATAD2, E2F8, ZNF367 and        TCF19;    -   optionally, a storage system for storing expression data        generated by the determination module; and    -   a display module for displaying a content based in part on the        data output from said determination module, wherein the content        comprises a signal indicative of the expression of the at least        two genes.

In one embodiment, the determination module is further configured toperform at least one test analysis on the test sample for dysregulationof p16^(INK4A) in combination with the test analysis on the at least twogenes (or proteins encoded by those genes).

In one embodiment, the system comprises a correlation module forcorrelating the expression data of the at least two genes (or proteinsencoded by those genes) from the determination module with recurrencepotential of cancer, wherein the expression data of each gene (or aprotein encoded by the gene) is compared with a reference value for thegene (or a protein encoded by the gene) to determine positive expressionof the gene (or a protein encoded by the gene), and wherein positiveexpression of the at least two genes (or proteins encoded by thosegenes) correlates with increased potential for recurrence compared withan individual with cancer who does not exhibit positive expression ofthe at least two genes (or proteins encoded by those genes), and whereinthe display module displays a content based in part on the data from thecorrelation system, the content optionally comprising a signalindicative of the recurrence potential of the cancer.

In one embodiment, the correlation module further correlates theexpression data of the at least two genes (or proteins encoded by thosegenes) from the determination module with recurrence potential ofcancer, together with the expression data of p16^(INK4A), wherein theexpression data of each gene (or a protein encoded by the gene) andp16^(INK4A) is compared with a reference value for each gene (or aprotein encoded by the gene) and p16^(INK4A), respectively, to determinepositive expression of the gene (or a protein encoded by the gene) anddysregulation of p16^(INK4A), and wherein positive expression of the atleast two genes (or proteins encoded by those genes) and dysregulationof p16^(INK4A) correlates with increased potential for recurrencecompared with an individual with cancer who does not exhibit positiveexpression of the at least two genes (or proteins encoded by thosegenes) and dysregulation of p16^(INK4A), and wherein the display moduledisplays a content based in part on the data from the correlationsystem, the content optionally comprising a signal indicative of therecurrence potential of the cancer.

Suitably, the determination system may be selected from animmunohistochemical detection apparatus, a Western Blot, a NorthernBlot, a Southern Blot, quantitative polymerase chain reaction (PCR),reverse transcriptase PCR (RT-PCR), quantitative real time RT-PCR(qRT-PCR), an enzyme-linked immunosorbent assay (ELISA), proteindetermination on polyacrylamide gels, and such methods known to thoseskilled in the art. Ideally, the determination system comprises animmunohistochemical detection apparatus.

In one embodiment of the invention, the content based on the comparisonresult or the determination system is displayed on a computer monitor.In one embodiment of the invention, the content based on the comparisonresult or determination system is displayed through printable media. Thedisplay module can be any suitable device configured to receive from acomputer and display computer readable information to a user.Non-limiting examples include, for example, general-purpose computerssuch as those based on Intel PENTIUM-type processor, Motorola PowerPC,Sun UltraSPARC, Hewlett-Packard PA-RISC processors, any of a variety ofprocessors available from Advanced Micro Devices (AMD) of Sunnyvale,Calif., or any other type of processor, visual display devices such asflat panel displays, cathode ray tubes and the like, as well as computerprinters of various types.

In one embodiment, a World Wide Web browser is used for providing a userinterface for display of the content based on the comparison result. Itshould be understood that other modules of the invention can be adaptedto have a web browser interface. Through the Web browser, a user mayconstruct requests for retrieving data from the comparison module. Thus,the user will typically point and click to user interface elements suchas buttons, pull down menus, scroll bars and the like conventionallyemployed in graphical user interfaces.

In one embodiment of the invention, there is provided a method formonitoring the effectiveness of treatment of cancer in an individualwith cancer, the method comprising a step of assaying a cancer samplefrom the individual with cancer for expression of at least two genesselected from the group consisting of FOXM1, UHRF1, PTTG1, E2F1, MYBL2,HMGB2, ATAD2, E2F8, ZNF367 and TCF19, wherein higher expression of atleast two genes selected from the group consisting of FOXM1, UHRF1,PTTG1, E2F1, MYBL2, HMGB2, ATAD2, E2F8, ZNF367 and TCF19 correlates withineffective treatment and poor outcome compared with an individual withcancer who has lower expression of the at least two genes.

In one embodiment, the method further comprises the step of assaying thecancer sample for expression of the p16^(INK4A) gene (or a proteinencoded by said gene) in combination with assaying the at least twogenes (or proteins encoded by said genes), whereby dysregulatedexpression of p16^(INK4A) correlates with ineffective treatment and pooroutcome compared with an individual with cancer who has moderateexpression of p16^(INK4A).

In one embodiment of the invention, there is provided a method fortreating cancer comprising the steps of:

-   -   identifying an individual with increased potential for        recurrence of cancer by assaying a cancer sample from the        individual for expression of at least two genes selected from        the group consisting of FOXM1, UHRF1, PTTG1, E2F1, MYBL2, HMGB2,        ATAD2, E2F8, ZNF367 and TCF19, wherein higher expression of at        least two genes selected from the group consisting of FOXM1,        UHRF1, PTTG1, E2F1, MYBL2, HMGB2, ATAD2, E2F8, ZNF367 and TCF19        correlates with increased potential for recurrence of cancer        compared with an individual with cancer who has lower expression        of the at least two genes; and    -   treating the individual with a therapeutically effective amount        of an adjuvant therapy.

In one embodiment, the individual is treated with a therapeuticallyeffective amount of a neoadjuvant therapy.

In one embodiment of the invention, there is provided a method fortreating cancer comprising the steps of:

-   -   identifying an individual with increased potential for        recurrence of cancer by assaying a cancer sample from the        individual for expression of at least two genes selected from        the group consisting of FOXM1, UHRF1, PTTG1, E2F1, MYBL2, HMGB2,        ATAD2, E2F8, ZNF367 and TCF19, wherein higher expression of at        least two genes selected from the group consisting of FOXM1,        UHRF1, PTTG1, E2F1, MYBL2, HMGB2, ATAD2, E2F8, ZNF367 and TCF19        correlates with increased potential for recurrence of cancer        compared with an individual with cancer who has lower expression        of the at least two genes; and    -   treating the individual with a therapeutically effective amount        of a neoadjuvant therapy.

In one embodiment, the individual is treated with a therapeuticallyeffective amount of an adjuvant therapy.

In one embodiment, the method further comprises the step of assaying thecancer sample for expression of the p16^(INK4A) gene (or a proteinencoded by said gene) in combination with assaying the at least twogenes (or proteins encoded by said genes), whereby dysregulatedexpression of p16^(INK4A) correlates with potential for recurrence ofcancer when compared with an individual with cancer who has moderateexpression of p16^(INK4A).

In one embodiment, the neoadjuvant therapy and adjuvant therapy is anagent selected from, but not limited to, trastuzumab (Herceptin®),lapatinib (Tykerb®), neratinib, afatinib (Tovok®), pertuzumab, CDK4/6inhibitors (such as palbociclib (PD 0332991, Pfizer), Abemaciclib(LY2835219; Lilly, USA), and LEE011 (Novartis, Switzerland)),cyclophosphamide, methotrexate, 5-fluorouracil, gemcitabine, adriamycin(doxorubicin), epirubucin, docetaxel (Taxotere®), paclitaxel (Taxol®),capecitabine (Xeloda®), and tamoxifen.

The invention also relates to a method of treating an individual toprevent or inhibit recurrence of the cancer comprising a step ofidentifying a cancer patient at risk of recurrence using a method of theinvention, and then treating the cancer patient with an agent or agentsto prevent or inhibit recurrence of the cancer. Typically, the agent oragents comprise adjuvant or neoadjuvant therapy, or a combination ofboth.

In one embodiment, there is provided a method of predicting risk ofrecurrence of cancer in an individual with cancer, the method comprisinga step of assaying a cancer sample from the individual for positiveexpression of at least four genes, or proteins encoded by said genes,selected from FOXM1, UHRF1, PTTG1, E2F1, MYBL2, HMGB2, ATAD2, E2F8,ZNF367 and TCF19, wherein positive expression of the at least fourgenes, or proteins encoded by said genes, correlates with increased riskof recurrence of cancer compared with an individual with cancer who doesnot exhibit positive expression of the at least four genes or proteinsencoded by those genes.

In one embodiment, there is provided a method of predicting risk ofrecurrence of cancer in an individual with cancer following treatmentwith CDK4/6 inhibitors, the method comprising a step of assaying acancer sample from the individual for positive expression of at leastfour genes, or proteins encoded by said genes, selected from FOXM1,UHRF1, PTTG1, E2F1, MYBL2, HMGB2, ATAD2, E2F8, ZNF367 and TCF19, whereinpositive expression of the at least four genes correlates with increasedrisk of recurrence of cancer in an individual with cancer followingtreatment with CDK4/6 inhibitors compared with an individual with cancerwho does not exhibit positive expression of the at least four genes orproteins encoded by those genes.

In one embodiment, there is provided a method of predicting risk ofrecurrence of breast cancer in an early stage, node negative breastcancer patient, the method comprising a step of assaying a cancer tumoursample from the patient for positive expression of at least four genes,or proteins encoded by those genes, selected from FOXM1, UHRF1, PTTG1,E2F1, MYBL2, HMGB2, ATAD2, E2F8, ZNF367 and TCF19, wherein positiveexpression of the at least four genes, or proteins encoded by thosegenes, correlates with increased risk of recurrence of cancer comparedwith a patient with cancer who does not exhibit positive expression ofthe at least four genes or proteins encoded by those genes.

In one embodiment, there is provided method of determining a 5-yearsurvival rate or a 10-year survival rate of an individual diagnosed withbreast cancer, the method comprising a step of assaying a cancer tumoursample from the individual for positive expression of at least fourgenes, or proteins encoded by those genes, selected from FOXM1, UHRF1,PTTG1, E2F1, MYBL2, HMGB2, ATAD2, E2F8, ZNF367 and TCF19, whereinpositive expression of the at least four genes, or proteins encoded bythose genes, correlates with decreased chance of 5-year survival rate or10-year survival rate compared with an individual with cancer who doesnot exhibit positive expression of the at least four genes or proteinsencoded by those genes.

In one embodiment, the methods further comprising the step of assayingfor the expression of p16^(INK4A) gene or a protein encoded by saidgene, wherein dysregulated expression of p16^(INK4A), in combinationwith positive expression of the at least four genes or proteins encodedby those genes, correlates with increased risk of recurrence of canceror a decreased chance of 5-year survival rate or 10-year survival ratecompared with an individual with cancer who does not exhibitdysregulated expression of p16^(INK4A) and positive expression of the atleast four genes or proteins encoded by those genes.

In one embodiment, there is provided a method of identifying a cancerpatient that is suitable for treatment with a therapy for preventingrecurrence or progression of the cancer, the method comprising a step ofassaying a cancer sample from the cancer patient for positive expressionof at least four genes selected from FOXM1, UHRF1, PTTG1, E2F1, MYBL2,HMGB2, ATAD2, E2F8, ZNF367 and TCF19, wherein positive expression of theat least four genes or proteins encoded by those genes compared with anindividual with cancer who does not exhibit positive expression of theat least two genes or proteins encoded by those genes, is indicativethat the cancer patient is suitable for treatment with a therapy forpreventing recurrence or progression of the cancer.

In one embodiment, there is provided a system for obtaining data from atleast one test sample obtained from at least one individual, the systemcomprising a determination module configured to receive at least onetest sample and perform at least one test analysis on the test sample toassay for expression of at least four genes or proteins encoded by thosegenes selected from FOXM1, UHRF1, PTTG1, E2F1, MYBL2, HMGB2, ATAD2,E2F8, ZNF367 and TCF19; optionally, a storage system for storingexpression data generated by the determination module; and a displaymodule for displaying a content based in part on the data output fromsaid determination module, wherein the content comprises a signalindicative of the expression of at the least two genes or proteinsencoded by those genes.

In one embodiment, there is provided a method for monitoring theeffectiveness of treatment of cancer in an individual with cancer, themethod comprising a step of assaying a cancer sample from the individualwith cancer for expression of at least four genes or proteins encoded bysaid genes selected from FOXM1, UHRF1, PTTG1, E2F1, MYBL2 and HMGB2,wherein higher expression of at least four genes selected from FOXM1,UHRF1, PTTG1, E2F1, MYBL2, HMGB2, ATAD2, E2F8, ZNF367 and TCF19correlates with ineffective treatment and poor outcome compared with anindividual with cancer who has lower expression of the at least fourgenes or proteins encoded by those genes.

In one embodiment, there is provided a method of predicting risk ofrecurrence or progression of breast cancer in a patient, and treatingthe patient with a therapy for preventing recurrence of the cancer, themethod comprising a step of assaying a cancer sample from the patientfor positive expression of at least four genes selected from FOXM1,UHRF1, PTTG1, E2F1, MYBL2, HMGB2, ATAD2, E2F8, ZNF367 and TCF19, whereinpositive expression of the at least four genes, or proteins encoded bythose genes, correlates with increased risk of recurrence or progressionof cancer compared with a patient with cancer who does not exhibitpositive expression of the at least four genes, or proteins encoded bythose genes; and administering a neoadjuvant or an adjuvant therapy, ora combination of both, to the patient to prevent recurrence orprogression of the cancer.

In one embodiment, the at least four genes, or proteins encoded by saidgenes, are FOXM1, PTTG1, UHRF1 and HMGB2.

BRIEF DESCRIPTION OF THE DRAWINGS

The invention will be more clearly understood from the followingdescription of an embodiment thereof, given by way of example only, withreference to the accompanying drawings, in which:—

FIGS. 1A-1E illustrate the Identification of master transcriptionalregulators (MTRs) of breast cell proliferation. FIG. 1A depicts Westernblot analysis of the proliferation marker EZH2 and the cellularsenescence marker p16INK4A in growing (low passage) and senescent (highpassage) human mammary epithelial cells (HMECs) and mouse embryonicfibroblasts (MEFs). β-actin was used as a loading control. FIG. 1Bdepicts Duplicate transcriptomic profiling experiments in growing andsenescent HMEC and MEF cultures were aligned in order to identify genesexpressed at a consistently high level in proliferating cells. Heat-mapanalysis depicts all genes up- or down-regulated by more than two-foldin HMECs, and the corresponding change in MEFs. (Cluster 1=58 genes;Cluster 2=193 genes; Cluster 3=184 genes; Cluster 4=214 genes). Cluster4 represents a ‘core proliferation’ signature comprising the genes mostsignificantly and consistently downregulated during serial passaging ofboth HMECs and MEFs. FIG. 1C depicts Quantitative real-time PCRvalidation of gene expression changes of representative genes from eachof the gene clusters shown in panel B. The ribosomal RNA gene, RPLPO,was used for normalization of these data. FIG. 1D depicts Gene ontologyanalysis of individual gene clusters. Red line indicates a p-value of0.05. FIG. 1E depicts Gene enrichment analysis of clusters 1-4 in theMammaPrint signature and the Genomic Grade signature. The fold change ofthe observed overlap versus what would be expected by chance isrepresented on the Y-axis. The number of ‘core proliferation’ genes (topnumber) present in each ‘poor prognosis’ signature (bottom number) isshown.

FIGS. 2A-2D illustrate that E2F1, FOXM1 and MYBL2 bind coreproliferative genes in HMECs. FIG. 2A depicts Reverse engineeringanalysis using ARACNe predicts 6 upstream Master TranscriptionalRegulators (MTRs) of the ‘core proliferation’ signature. Shown is arepresentative ARACNe network of the HMEC/MEF ‘core proliferation’signature (Cluster 4) within the NKI dataset (van de Vijver et al.,2002). MTRs are highlighted in red, and cluster 4 genes are highlightedin green. FIG. 2B depicts Validation of MTR binding to genes within the‘core proliferation’ signature by ChIP-qRT-PCR. Precipitated DNA wasanalyzed by qRT-PCR using primers directed towards the promoters of theindicated genes (SEQ ID NOs: 1 to 38). Anti-HA antibody was used as anegative control for ChIP, and the β-ACTB and CHD5 promoters were usedas negative promoter controls for qRT-PCR. ChIP enrichments arepresented as the percentage of protein bound, normalised to input. Theerror bars indicate standard deviation of three technical replicates.FIG. 2C depicts Heat-map analysis showing ChIP-seq data for FOXM1, MYBL2and E2F1, in HMEC-Tert cells. Binding at the promoters of genes fromClusters 1-4 is indicated by increasing signal for each factor, FOXM1MYBL2 and E2F1. The region between −2 and +2 of the transcriptionalstart site (TSS) of these genes is shown. FIG. 2D depicts RepresentativeChIP-seq tracks of the indicated genes, with FOXM1, MYBL2 and E2F1 boundat their promoters in HMEC-Tert cells. RNA-seq data from both low andhigh passage HMECs is also depicted for each gene. The KRT2 gene isincluded as a negative control.

FIGS. 3A-3E illustrate that master transcriptional regulators predictpatient outcome. FIG. 3A demonstrates that Master transcriptionalregulators are predicted to be upstream of the ‘Genomic Grade’ poorprognosis signature. Shown is a representative ARACNe network of the‘Genomic Grade’ signature (Sotiriou et al., 2006) within the Loi dataset(Loi et al., 2007). MTRs and Genomic Grade signature genes arehighlighted. In FIG. 3B, Kaplan-Meier analyses demonstrate that thecombination of the 6 MTRs (upper) exhibit superior prognostic value thanKi67 (lower) in node negative samples without adjuvant chemotherapy inthe combined microarray dataset in terms of recurrence-free survival(Loi et al., 2007; Miller et al., 2005; and van de Vijver et al., 2002)(n=457). The MTR combined score and Ki67 gene expression data were splitas 2 (Lo/Hi) and 3 (Lo/Med/Hi) groups. FIG. 3C depicts Representativeexamples of immunohistochemical staining for the indicated factors inlow and high-risk tumors on a breast cancer tissue microarray. Low risktumors were defined as those that did not recur within the studytimeframe, whereas high risk tumors did recur. FIG. 3D depictsKaplan-Meier survival curves for FOXM1, UHRF1, HMGB2 and PTTG1 combined,compared to Ki67 and the St. Gallen criteria in TMA samples (n=408) interms of recurrence-free survival. FIG. 3E depicts Heat map illustratingthe prognostic power of FOXM1, UHRF1, HMGB2 and PTTG1 and the 4 MTRscombined on the breast tumours from the TMA cohort (n=408) in terms ofrecurrence-free survival. Ki67 staining results and St. Gallen criteriawere included for comparison. The scale represents −log 10 of thep-values calculated using log-rank test.

FIGS. 4A-4E illustrates that absent and high CDKN2A mRNA and p16 proteinlevels predict poor prognosis in breast cancer. FIG. 4A depictsCorrelations of the mRNA expression levels of CDKN2A with gene copynumber alterations (CNA) in the RB1 and CDKN2A gene loci using theGISTIC tool on data 457 breast cancers from TCGA (TCGA, 2012, Nature,490, 61-70). FIG. 4B depicts Kaplan-Meier survival curves for CDKN2AmRNA in node negative breast cancers without adjuvant chemotherapy inthe combined microarray dataset (n=457) in terms of recurrence-freesurvival. Samples were stratified into 3 groups based on CDKN2A mRNAexpression levels, cut at the 33rd and 66th percentile. Additionally,the undetected and high expression groups were combined and compared tothe moderate expression group. Chi2 values and p-values were calculatedusing log-rank test. FIG. 4C depicts Representative examples ofimmunohistochemical staining for p16 on low and high-risk tumors. Lowrisk tumors were defined as those which did not recur within the studytimeframe, whereas high risk tumors did recur. FIG. 4D depictsKaplan-Meier survival curves for p16 protein levels in the TMA cohort(n=408) measuring recurrence-free survival. Patients were stratified byp16 protein levels into negative, moderate (<50% positive cells) andhigh expression (>50% positive cells) groups. Chi2 values and p-valueswere calculated using log-rank test. FIG. 4E depicts Kaplan-Meiersurvival curves for p16 protein levels in the TMA cohort (n=408)measuring breast cancer-specific survival. Patients were stratified asin FIG. 4C.

FIGS. 5A-5D illustrate that combined measurements of MTR and p16(INK4A)levels outperforms estimates of currently used strategies. FIG. 5Adepicts Kaplan-Meier survival curves comparing the prognostic value ofthe OncoMasTR RNA score (combination of CDKN2A and 6 MTRs) withestimates of the Oncotype Dx (21-gene) and Mammaprint (70-gene)signatures in node negative samples without adjuvant chemotherapy in thecombined microarray dataset (n=457) in terms of recurrence-freesurvival. Both low/moderate/high and low/high splits were used tofacilitate comparison to existing prognostic signatures. FIG. 5B depictsHeat maps illustrating the prognostic value of CDKN2A alone, 6 MTRscombined, OncoMasTR RNA score, 70-gene signature, 21-gene signature andKi67 in node negative samples without adjuvant chemotherapy in threeindividual breast cancer microarray datasets (Loi et al., 2007; Milleret al., 2005; and van de Vijver et al., 2002) and the combined dataset(n=457) in terms of recurrence-free survival. The 70-gene and 21-genesignature predicted risk groups were estimated based on gene expressiondata using the genefu package in R. The scale represents −log 10 of thep-values calculated using log-rank test. Both 2 and 3 group splits wereused to facilitate comparison to existing prognostic signatures. FIG. 5Cdepicts Kaplan-Meier survival curves illustrating the combined score of4 MTRs (FOXM1, UHRF1, HMGB2, PTTG1) and p16 (OncoMasTR IHC score) in allsamples (left, n=408) and node negative samples (right, n=222) from theTMA cohort using recurrence-free survival data. The prognostic values ofthe 4 MTRs alone, p16 alone, the OncoMasTR IHC score, Ki67 and St.Gallen criteria were represented as a heat map based on the −log 10 ofp-values calculated using the log-rank test. FIG. 5D depictsKaplan-Meier survival as in FIG. 5C, using breast cancer specificsurvival data.

FIGS. 6A-6B illustrate the performance of the OncoMasTR RNA score inER-positive patients. FIG. 6A depicts Kaplan-Meier survival curvescomparing the prognostic value of the OncoMasTR RNA score (6 MTRs andCDKN2A) with the 21-gene and 70-gene signatures in ER-positive patientswho did not receive adjuvant chemotherapy, in the combined microarraydataset (n=536) in terms of recurrence-free survival. FIG. 6B depictsKaplan-Meier survival curves as in FIG. 6A. in lymph-node negative,ER-positive patients who did not receive adjuvant chemotherapy, in thecombined microarray dataset (n=366).

FIG. 7 illustrates the performance of the OncoMasTR RNA score asmeasured by Taqman qRT-PCR. Kaplan-Meier survival curves demonstratingthe prognostic value of the OncoMasTR RNA score (4 MTRs+/−CDKN2A) asindicated in ER-positive, lymph-node negative patients in the NKIdataset who did not receive adjuvant chemotherapy (n=151), in terms ofdistant metastasis-free survival. Patients were divided into Low andHigh risk groups, and Low, Moderate and High risk groups as indicated.To do this, expression data for each MTR gene was used to split patientsinto low/high groups at the median. The sum of the 6 MTR (+/−CDKN2A)were taken and further split by median (2 groups) or by 33th and 66thpercentile (3 groups). The end point is DMFS (censored at 10 years).

FIG. 8 illustrates the performance of the OncoMasTR IHC score in termsof Distant Metastasis-free survival. Kaplan-Meier survival curvesdemonstrating the prognostic value of the OncoMasTR IHC score (4MTRs+/−CDKN2A) as indicated in lymph-node negative patients (LN−)(n=220), ER-positive patients (ER+) (n=331), and LN-ER+ patients(n=187), who did not receive adjuvant chemotherapy, in terms of distantmetastasis-free survival.

FIG. 9 illustrates the prognostic value of additional MTRs—ATAD2 andTCF19. Kaplan-Meier survival curves demonstrating the prognostic valueof ATAD2 and TCF19 within ER-positive, lymph-node negative patients inthe combined microarray dataset (n=375), in terms of distantmetastasis-free survival, censored at 10 years. The gene expressionvalues for ATAD2 and TCF19 were split into low/high groups by the medianwithin each of the three datasets. There are no probes mapping to E2F8and ZNF367 in the NKI dataset.

FIG. 10 illustrates Kaplan-Meier survival curves for 6 MTRs (FOXM1,UHRF1, MYBL2, HMGB2, E2F1, PTTG1) in The Cancer Genome Atlas (TGCA)prostate cancer transcriptomic dataset (n=150) in terms ofmetastasis-free survival.

FIG. 11 illustrates a Forest plot of the top 100 combinations of MTRsfrom the list of 10 MTRs described here, with at least 4 MTRs in eachcombination.

FIG. 12 illustrates Kaplan-Meier plots of the top 24 MTR combinations.In each case, the black line refers to high expression of the markercombination and grey refers to low expression of the marker combination.

FIG. 13 illustrates the MTR10 and CDKN2A signature score in pablociclibtreated human cell lines.

DETAILED DESCRIPTION OF THE DRAWINGS Definitions

In this specification, the term “cancer sample” should be understood tomean tumour cells, tumour tissue, or other biological material derivedfrom a tumour, for example conditioned media.

In the specification, the term “Master Transcriptional Regulators(MTRs)” should be understood to mean a specific set of TranscriptionFactors (TFs) that are upstream of, and have been shown to regulate,core proliferation genes involved in cancer progression and metastasis.In other words, these specific MTRs regulate cancer and in particular,breast cancer progression.

In the specification, the term “positive expression” as applied to agene or a protein encoded by that gene should be understood to mean alevel of expression of the gene or protein encoded by that gene that isincreased above an average level of expression of the same gene orprotein encoded by that same gene found in a cohort of matched controlindividuals with cancer (the “control group”). The cohort of matchedindividuals may consist of individuals who did not experience arecurrence of a cancer following surgery to remove the cancer. Inrelation to controls, the usual practise for one skilled in the artwould be to use a ‘standard’ control, for example, forImmunohistochemistry (IHC), a cell line or cell lines where theexpression level of the biomarker is known, or for qPCR (quantitativePolymerase Chain Reaction), a similar standard control or a pool of anumber of samples is known.

In the specification, the term “dysregulated expression” as applied top16^(INK4A) expression should be understood to mean a level ofexpression of p16^(INK4A) that is negative, increased above or decreasedbelow a level of expression of the p16^(INK4A) found in a cohort ofmatched individuals with cancer that did not recur following surgery toremove the cancer.

The terms “normal expression” or “moderate expression” as applied to agene or protein should be understood to mean a level of expression ofthe gene (or protein encoded by that gene) that is equivalent to a levelof expression of the same gene or protein encoded by that same genefound in a cohort of matched control individuals with cancer. The cohortof matched individuals may consist of individuals who did not experiencea recurrence of a cancer following surgery to remove the cancer.

The method used to set thresholds is different for the microarrayanalysis, qRT-PCR analysis, and protein expression. For microarrays, thethreshold is relative (samples were split into three equal groups, sothe threshold is dataset dependent), and for the qPCR and proteinexpression it is set at specific points. For RNA (microarrays),expression levels of ‘low’, ‘moderate’ and ‘high’ refer to expressionvalues that fall within the lower, middle or upper third of theexpression range; or alternatively, ‘low’ and ‘high’ expression canrefer to expression values that fall within the lower or upper half ofthe expression range. For qRT-PCR and protein expression levels,specific thresholds have been set, but in general, the term“dysregulated” refers to tumours with expression values falling above orbelow set values in the range of expression. For the terms “moderate”and “normal”, the terms refer to tumours with expression values fallingwithin set values in the range of expression. For example, forp16^(INK4A), the normalised qRT-PCR thresholds for ‘moderate’ expressionare 0.7 and 1.99. The normalised protein thresholds (using IHC) are 1%and 50% of positive cells. That is, a moderate score here refers to atumour with >1% and <50% tumour cells positive for p16^(INK4A). Thesevalues may be adjusted based on any new data but the same theory appliesfor the terms “normal”, “moderate” and “dysregulated” with respect toexpression levels of p16^(INK4A).

In the specification, the term “adjuvant therapy” should be understoodto mean any treatment given after primary treatment to increase thechances of long-term survival. In the specification, the term“neoadjuvant therapy” should be understood to mean treatment givenbefore primary treatment to increase the chances of long-term survival.Primary treatment is generally surgery. Adjuvant therapy and neoadjuvanttherapy are generally selected from chemotherapy, hormonal therapy,targeted therapy, radiation therapy, immunotherapy or a combinationthereof.

In the specification, the term “sample” should be understood to meantumour cells, tumour tissue, non-tumour tissue, conditioned media, bloodor blood derivatives (serum, plasma etc), urine, or cerebrospinal fluid.

Detection of expression generally involves immunohistological stainingof a tumour biopsy tissue or a control biopsy tissue using suitablemeans such as immunohistochemical staining; however, many other means ofdetecting the biomarkers of the invention will be apparent to thoseskilled in the art. For example, quantitative polymerase chain reaction(PCR), reverse transcriptase PCR (RT-PCR), quantitative real time RT-PCR(qRT-PCR), ELISA, Western Blot, protein determination on polyacrylamidegels, and the like.

In this specification, the term “cancer” should be understood to mean acancer that is treated by chemotherapeutic regimens. An example of sucha cancer include multiple myeloma, prostate cancer, glioblastoma,lymphoma, fibrosarcoma; myxosarcoma; liposarcoma; chondrosarcom;osteogenic sarcoma; chordoma; angiosarcoma; endotheliosarcoma;lymphangiosarcoma; lymphangioendotheliosarcoma; synovioma; mesothelioma;Ewing's tumour; leiomyosarcoma; rhabdomyosarcoma; colon carcinoma;pancreatic cancer; breast cancer; node-negative, ER-positive breastcancer; early stage, node positive breast cancer; early stage, nodepositive, ER-positive breast cancer; ovarian cancer; squamous cellcarcinoma; basal cell carcinoma; adenocarcinoma; sweat gland carcinoma;sebaceous gland carcinoma; papillary carcinoma; papillaryadenocarcinomas; cystadenocarcinoma; medullary carcinoma; bronchogeniccarcinoma; renal cell carcinoma; hepatoma; bile duct carcinoma;choriocarcinoma; seminoma; embryonal carcinoma; Wilms' tumour; cervicalcancer; uterine cancer; testicular tumour; lung carcinoma; small celllung carcinoma; bladder carcinoma; epithelial carcinoma; glioma;astrocytoma; medulloblastoma; craniopharyngioma; ependymoma; pinealoma;hemangioblastoma; acoustic neuroma; oligodendroglioma; meningioma;melanoma; retinoblastoma; and leukemias.

In this specification, the term “early stage” as applied to a cancer,especially a breast cancer, should be understood to mean tumours whichare locally invasive but have not spread to the regional axillary lymphnodes or any other region of the body outside the breast tissue. Thatis, the cancer has not spread beyond the breast or the lymph nodes inthe armpit on the same side of the body nor to any other part of thebody.

In the specification, the term “early stage, node positive breastcancer” should be understood to mean tumours which are locally invasiveand have spread to between 1-3 regional axillary lymph nodes, but not toany other region of the body outside the breast tissue.

In this specification, the term “node-negative” as applied to a cancer,especially a breast cancer, should be understood to mean tumours whichhave not spread to the regional axillary lymph nodes or any regionoutside the breast tissue.

In the specification, the terms “breast cancer patient” or “patient”means a patient who has a primary breast cancer tumour and awaitstreatment for the cancer or has already undergone or is undergoingtreatment for the primary tumour. The term should also be understood toinclude a patient who has had a primary breast cancer and is inremission, for example remission following treatment including one ormore of tumour resection, first line chemotherapy, radiotherapy,hormonal therapy, other targeted therapy, or a combination of the above.Usually, the patient will be a breast cancer patient who has, or isundergoing, treatment for a primary tumour and who has been identifiedas having potential for developing a metastatic phenotype. In oneembodiment, the patient has an ER-positive, node negative breast cancer.

In the specification, the term “recurrence” should be understood to meanthe recurrence of the cancer which is being sampled in the patient, inwhich the cancer has returned to the sampled area after treatment, forexample, if sampling breast cancer, recurrence of the breast cancer inthe (source) breast tissue. The term should also be understood to meanrecurrence of a primary cancer whose site is different to that of thecancer initially sampled, that is, the cancer has returned to anon-sampled area after treatment, such as non-locoregional recurrences.

In this specification, the term “poor outcome” should be understood tomean that the chances of disease free survival are low.

In the specification, the term “survival rate” should be understood tomean the period of time during which a patient diagnosed with cancersuch as breast cancer, will likely survive. The survival rate isexpressed as a 5-year survival rate, a 10-year survival rate, a 15-yearsurvival rate, a 20-year survival rate, a 25-year survival rate, a30-year survival rate, a 35-year survival rate, a 40-year survival rate,a 45-year survival rate, or a 50-year survival rate. Ideally, thesurvival rate is expressed as a 5-year survival rate or a 10-yearsurvival rate.

In this specification, the term “treatment” should be understood to meanits generally accepted meaning which encompasses prohibiting,preventing, restraining, and slowing, stopping or reversing progressionor severity of a metastatic, recurrent or existing breast cancerphenotype or other cancer phenotype.

In this specification, the term “at least two” should be understood tomean and encompass that at least two, at least three, at least four, atleast five, at least six, at least seven, at least eight, at least nineor all genes can be selected from the group consisting of FOXM1, UHRF1,PTTG1, E2F1, MYBL2, HMGB2, ATAD2, E2F8, ZNF367 and TCF19.

The computer readable storage media can be any available tangible mediathat can be accessed by a computer. Computer readable storage mediaincludes volatile and non-volatile, removable and non-removable tangiblemedia implemented in any method or technology for storage of informationsuch as computer readable instructions, data structures, program modulesor other data. Computer readable storage media includes, but is notlimited to, RAM (random access memory), ROM (read only memory), EPROM(erasable programmable read only memory), EEPROM (electrically erasableprogrammable read only memory), flash memory or other memory technology,CD-ROM (compact disc read only memory), DVDs (digital versatile disks)or other optical storage media, magnetic cassettes, magnetic tape,magnetic disk storage or other magnetic storage media, other types ofvolatile and non-volatile memory, and any other tangible medium whichcan be used to store the desired information and which can accessed by acomputer including and any suitable combination of the foregoing.

Computer-readable data embodied on one or more computer-readable storagemedia may define instructions, for example, as part of one or moreprograms that, as a result of being executed by a computer, instruct thecomputer to perform one or more of the functions described herein,and/or various embodiments, variations and combinations thereof. Suchinstructions may be written in any of a plurality of programminglanguages, for example, Java, J#, Visual Basic, C, C#, C++, Fortran,Pascal, Eiffel, Basic, COBOL assembly language, and the like, or any ofa variety of combinations thereof. The computer-readable storage mediaon which such instructions are embodied may reside on one or more of thecomponents of either of a system, or a computer readable storage mediumdescribed herein, may be distributed across one or more of suchcomponents.

The computer-readable storage media may be transportable such that theinstructions stored thereon can be loaded onto any computer resource toimplement the aspects of the present invention discussed herein. Inaddition, it should be appreciated that the instructions stored on thecomputer-readable medium, described above, are not limited toinstructions embodied as part of an application program running on ahost computer. Rather, the instructions may be embodied as any type ofcomputer code (e.g., software or microcode) that can be employed toprogram a computer to implement aspects of the present invention. Thecomputer executable instructions may be written in a suitable computerlanguage or combination of several languages. Basic computationalbiology methods are known to those of ordinary skill in the art and aredescribed in, for example, Setubal and Meidanis et al., Introduction toComputational Biology Methods (PWS Publishing Company, Boston, 1997);Salzberg, Searles, Kasif, (Ed.), Computational Methods in MolecularBiology, (Elsevier, Amsterdam, 1998); Rashidi and Buehler,Bioinformatics Basics: Application in Biological Science and Medicine(CRC Press, London, 2000) and Ouelette and Bzevanis Bioinformatics: APractical Guide for Analysis of Gene and Proteins (Wiley & Sons, Inc.,2nd ed., 2001).

The functional modules of certain embodiments of the invention includeat minimum a determination system, a storage device, optionally acomparison module, and a display module. The functional modules can beexecuted on one, or multiple, computers, or by using one, or multiple,computer networks. The determination system has computer executableinstructions to provide e.g., expression levels of at least two genes(or a protein encoded by said genes) selected from the group consistingof FOXM1, UHRF1, PTTG1, E2F1, MYBL2 and HMGB2, and optionally includingp16^(INK4A), in computer readable form.

The determination system, can comprise any system for assaying a breastcancer tumour sample for expression of genes (or proteins encoded bysaid genes) selected from the group consisting of FOXM1, UHRF1, PTTG1,E2F1, MYBL2, HMGB2, ATAD2, E2F8, ZNF367, TCF19 and p16^(INK4A). Standardprocedures, such as immunohistochemistry, a Western Blot, a NorthernBlot, a Southern Blot, quantitative polymerase chain reaction (PCR),reverse transcriptase PCR (RT-PCR), quantitative real time RT-PCR(qRT-PCR), an enzyme-linked immunosorbent assay (ELISA), proteindetermination on polyacrylamide gels, RNA sequencing, RNA microarraysand other RNA hybridisation or amplification techniques, and suchmethods known to those skilled in the art, may be employed.

The information determined in the determination system can be read bythe storage device. As used herein the “storage device” is intended toinclude any suitable computing or processing apparatus or other deviceconfigured or adapted for storing data or information. Examples of anelectronic apparatus suitable for use with the present invention includea stand-alone computing apparatus, data telecommunications networks,including local area networks (LAN), wide area networks (WAN), Internet,Intranet, and Extranet, and local and distributed computer processingsystems. Storage devices also include, but are not limited to: magneticstorage media, such as floppy discs, hard disc storage media, magnetictape, optical storage media such as CD-ROM, DVD, electronic storagemedia such as RAM, ROM, EPROM, EEPROM and the like, general hard disksand hybrids of these categories such as magnetic/optical storage media.The storage device is adapted or configured for having recorded thereonnucleic acid sequence information. Such information may be provided indigital form that can be transmitted and read electronically, e.g., viathe Internet, on diskette, via USB (universal serial bus) or via anyother suitable mode of communication.

As used herein, “stored” refers to a process for encoding information onthe storage device. Those skilled in the art can readily adopt any ofthe presently known methods for recording information on known media togenerate manufactures comprising information relating to FOXM1, UHRF1,PTTG1, E2F1, MYBL2, HMGB2, ATAD2, E2F8, ZNF367, TCF19 and p16^(INK4A)expression in a sample.

In one embodiment the reference data stored in the storage device to beread by the comparison module is compared.

The “comparison module” can use a variety of available software programsand formats for the comparison operative to compare FOXM1, UHRF1, PTTG1,E2F1, MYBL2, HMGB2, ATAD2, E2F8, ZNF367, TCF19 and p16^(INK4A)expression information data determined in the determination system toreference samples and/or stored reference data. In one embodiment, thecomparison module is configured to use pattern recognition techniques tocompare information from one or more entries to one or more referencedata patterns. The comparison module may be configured using existingcommercially-available or freely-available software for comparingpatterns, staining, and may be optimized for particular data comparisonsthat are conducted. The comparison module provides computer readableinformation related to the expression levels of FOXM1, UHRF1, PTTG1,E2F1, MYBL2, HMGB2, ATAD2, E2F8, ZNF367, TCF19 and p16^(INK4A) of thesample.

The comparison module, or any other module of the invention, may includean operating system (e.g., UNIX) on which runs a relational databasemanagement system, a World Wide Web application, and a World Wide Webserver. World Wide Web application includes the executable codenecessary for generation of database language statements (e.g.,Structured Query Language (SQL) statements). Generally, the executableswill include embedded SQL statements. In addition, the World Wide Webapplication may include a configuration file which contains pointers andaddresses to the various software entities that comprise the server aswell as the various external and internal databases which must beaccessed to service user requests. The Configuration file also directsrequests for server resources to the appropriate hardware—as may benecessary should the server be distributed over two or more separatecomputers. In one embodiment, the World Wide Web server supports aTCP/IP protocol. Local networks such as this are sometimes referred toas “Intranets.” An advantage of such Intranets is that they allow easycommunication with public domain databases residing on the World WideWeb (e.g., the GenBank or Swiss Pro World Wide Web site). Thus, in aparticular preferred embodiment of the present invention, users candirectly access data (via Hypertext links for example) residing onInternet databases using a HTML interface provided by Web browsers andWeb servers.

The comparison module provides a computer readable comparison resultthat can be processed in computer readable form by predefined criteria,or criteria defined by a user, to provide a content based in part on thecomparison result that may be stored and output as requested by a userusing a display module.

The methods described herein therefore provide for systems (and computerreadable media for causing computer systems) to perform methods asdescribed in the Statements of Invention above, for example methods fordiagnosing metastatic potential or recurrence potential of a breastcancer or a non-breast cancer in an individual or methods foridentifying a breast cancer patient or a non-breast cancer patientsuitable for treatment or prevention of metastatic or recurrent cancerwith a suitable chemotherapeutic adjuvant or non-adjuvant therapeutic.

Systems and computer readable media described herein are merelyillustrative embodiments of the invention for performing methods ofdiagnosis in an individual, and are not intended to limit the scope ofthe invention. Variations of the systems and computer readable mediadescribed herein are possible and are intended to fall within the scopeof the invention.

The modules of the machine, or those used in the computer readablemedium, may assume numerous configurations. For example, function may beprovided on a single machine or distributed over multiple machines.

Materials and Methods

Cell Culture

Primary HMEC cells were grown as described (Garbe et al., 2009).HMEC-tert cells were immortalised using a pBABE-hTERT-hygro construct.Mouse embryonic fibroblasts (MEFs) were derived from embryonic day 13.5C57BL6 mouse embryos and maintained in DMEM media supplemented with 10%(v/v) FBS (Hyclone), 100 U/ml penicillin and 100 U/ml streptomycin(Gibco).

RNA Sequencing

Total RNA was extracted from proliferating and senescent HMECs using theRNeasy kit (Qiagen). Polyadenylated RNA species were enriched from 5 gtotal RNA, and sequencing libraries were prepared from PolyA+ RNA usingthe TruSeq Sample Prep kit (Illumina). Libraries were used directly forcluster generation and sequencing analysis using the Genome Analyser II(Illumina) following the protocol of the manufacturer. Base calling andmapping to the human genome (build hg19) were performed using the BWAsequence alignment tool. The mRNA fold changes were calculated based onthe total number of sequence reads mapped per gene in the twoexperiments.

DNA Microarray Analysis

Total RNA was extracted from proliferating and senescent MEFs using theRNeasy kit (Qiagen). For each time point, RNA was prepared from threeindependent MEF cultures and pooled to reduce experimental variation.Cy3 labeled cRNA, for use with a custom designed 44 k microarray(Agilent), was prepared and hybridized to the supplier's instructions.Microarrays were scanned using Agilent's DNA microarray scanner and dataanalysed as previously described (Hokamp et al., 2004). Gene ontologyanalysis was carried out using the DAVID bioinfomrnatics resource(available on the world wide web at david.abcc.ncifcrf.gov/). Publiclyavailable breast cancer microarray datasets were downloaded from RosettaInpharmatics and Gene Expression Omnibus (GSE6532 and GSE3494). Withineach dataset, the expression data of each gene was divided at the medianinto two groups, or at the 33^(rd) and 66^(th) percentile into 3 groups,depending on the analysis. To generate a combined MTR score, the geneexpression values for each of the 6 genes were divided at the median,given a score of 1 or 2 based on the expression level, and the sum ofthese scores was then divided, as above, to create 2 or 3 groups. INK4Agene expression was divided into 3 groups (low, moderate and high) atthe 33^(rd) and 66^(th) percentile. The moderate group was given a scoreof 1 and the low and high groups were combined and given a score of 2.To generate the OncoMasTR RNA score, the combined MTR score and theINK4A score were summed together and the final scores were divided into2 or 3 groups. Duplicate samples were removed in the combined microarraydataset. The genefu package in R was used to estimate the risk groupswhich approximate the Oncotype Dx® assay (based on 21-gene signature),and the MammaPrint assay (based on 70-gene signature) (Haibe-Kains etal). For the Van de Vijver dataset, the previously defined 70-gene riskgroups were used (van de Vijver et al., 2002).

Real-Time Quantitative PCR

Total RNA was extracted from cells using the RNeasy kit (Qiagen)according to manufacturer's protocol. lug RNA was used to generate cDNAby reverse transcriptase PCR using the TaqMan Reverse Transcription kit(Applied Biosytems). Relative mRNA expression levels were determinedusing the SYBR Green I detection chemistry (Applied Biosystems) on theABI Prism 7500 Fast Real-Time PCR System. The ribosomal constituentRPLPO was used as a control gene for normalization (SEQ ID NO: 39(Forward—TTCATTGTGGGAGCAGAC) and SEQ ID NO: 40(Reverese—CAGCAGTTTCTCCAGAGC)). Primer sequence pairs used are asfollows (For =Forward Primer; Rev=Reverse Primer):

For: SEQ ID NO: 1 AGACCGTCCTCAACCAGCTCTTC and Rev: SEQ ID NO: 2GAAGTGCTTGGAGATCACCGG; For: SEQ ID NO: 3CAA CAA TAG CCT ATC CAA CAT CCA G and Rev: SEQ ID NO: 4GGA GCC CAG TCC ATC AGA ACT C; For: SEQ ID NO: 5 CTGCCTGAAGAGCACCAGATTGand Rev: SEQ ID NO: 6 CAAGGATCATGAGAGGCACTCC; For: SEQ ID NO: 7CACTGACCAGCAATGCCAGTAC and Rev: SEQ ID NO: 8 CCCCTTGACAAGGTCTGGATTC;For: SEQ ID NO: 9 GCTCCTAAAAGGCCACCATCTG and Rev: SEQ ID NO: 10TGATCTTTGGGCGATGTTCAG; For: SEQ ID NO: 11 TGT CAG GAC CTT CGT AGC ATT Gand Rev: SEQ ID NO: 12 GGG CTT TGA TCA CCA TAA CCA TC; For:SEQ ID NO: 13 CAA TCT CAA CAA AAC CCT TGG C and Rev: SEQ ID NO: 14CTC GGC GTA CTT ATT CTC CTC C; For: SEQ ID NO: 15 AGAGGATTTGAGGGACAGGGTCand Rev: SEQ ID NO: 16 CCTCTTTCTTCCTCCGGTGC; For: SEQ ID NO: 17ATGGAGCTGGGTGCTGAGAAC and Rev: SEQ ID NO: 18 CCTTCTTCAACTCCATGAGCCC;For: SEQ ID NO: 19 ACA AAG AAG GAA ATA GAG GGA CCG and Rev:SEQ ID NO: 20 GAT GAG TGG GAG ACT TGG GTT C; For: SEQ ID NO: 21CAGCCCGAGCTTTTGTTACAAC and Rev: SEQ ID NO: 22 TTCGCTGCTGACATCTGAGTTC;For: SEQ ID NO: 23 AAGGTGAGCAAGATGGAAATCC and Rev: SEQ ID NO: 24CGATCTGCAGGTCCAAGATGTAG For: SEQ ID NO: 25 CTCTCTGAGGCCAAGGATCTCC andRev: SEQ ID NO: 26 CCTTGTTGCAGTATTTGCAGTTG; For: SEQ ID NO: 27TGAGCCTGCAGATTTTAAGGTG and Rev: SEQ ID NO: 28 TGGAAAGCTTCTCACGGCATAC;For: SEQ ID NO: 29 AGCTGGCCTGAATCATTAATACG and Rev: SEQ ID NO: 30GGTGAAGGTCCATGAGACAAGG; For: SEQ ID NO: 31 GGGACAGTAAAAATGTGTCCTGC andRev: SEQ ID NO: 32 TGCCAGCAATAGATGCTTTTTG; For: SEQ ID NO: 33CAT TCC CGC TCT CCT TCC C and Rev: SEQ ID NO: 34GCT CGG CTC CCC AGA ATC; For: SEQ ID NO: 35 CCTCACTGGAGGAGTGATGCG andRev: SEQ ID NO: 36 AAGCATCCTAAGCCATTCCATG; For: SEQ ID NO: 37CCA TTG AAA ACA AGG ACG ATG C and Rev: SEQ ID NO: 38CTG TCC CCA ACA ACA TCA AGC.

ChIP and ChIP-Sequencing

ChIP analyses were performed as described previously (Bracken et al.,2006). For ChIP-SEQ, DNA from 10 independent ChIP experiments was pooledand quantified using a Qubit fluorometer (Invitrogen). Sequencinglibraries were generated using 100 ng of immunoprecipitated DNA usingthe ChIP-SEQ Sample Prep Kit (Illumina). Amplified library DNA waspurified by gel isolation and quality checked to unsure the absence ofadaptor dimer contamination using the Bioanalyzer 2100 and DNA HighSensitivity Chip assay (Agilent). DNA libraries were quantified anddiluted to 10 μM. Diluted libraries were used directly for clustergeneration and sequencing analysis using the Genome Analyser II(Illumina) following the protocol of the manufacturer. Base calling andmapping to the human genome (hg19) of the 42-bp sequences were doneusing the Bowtie alignment tool allowing for up to 2 mismatches in eachread. To avoid any PCR bias only two reads per chromosomnal positionwere allowed, thus eliminating spurious spikes. Peak detection wasperformed using MACs, and Input DNA was used as a control fornormalization.

ARACNe Analysis

Breast cancer transcriptional networks were generated by ARACNe(Margolin et al., 2006), using published breast cancer datasets (ExPO;Loi et al., 2007; van de Vijver et al., 2002), and queried usingin-house or published gene signatures. For the ExPO and Loi networks,ARACNe was run on the complete expression datasets, whereas for the NKInetwork, a filtering step was applied prior to ARACNe to removeuninformative probes. The 70 gene Mammaprint signature was derivedthough supervised classification of DNA microarray data from 78 lymphnode-negative patients, and predicts a short time to distant metastasis(van 't Veer et al., 2002). The larger 231-gene signature from which the70-gene signature was derived was used for this analysis. The GenomicGrade signature was developed from a training dataset of 64 ER-positivebreast tumors, and is composed of genes differentially expressed betweenlow and high histologic grade. The larger 207-gene set list from whichthe 97-gene Genomic Grade Index was derived was used for ARACNe analysis(Sotiriou et al., 2006).

Statistical Analysis

Kaplan-Meier survival curves were used for survival analysis and Chisquare and p-values were calculated using log-rank test. MultivariateCox proportional hazards analysis was used to evaluate the addedprognostic value of individual genes and combined scores, on top of astandard clinical model including age (<50, >=50 years), nodal status(positive or negative), tumour size (<2 cm, >=2 cm), tumour grade (1 vs.2 and 3), treatment status, and ER and HER2 status. Multivariateanalysis was also carried out using the standard clinical model above,plus the 21-gene signature predicted risk group. The contribution ofeach marker was assessed by the change in likelihood ratio (LR-Chi,df=1) and p-values were calculated. A p-value of less than 0.05 wasconsidered significant. The primary clinical endpoint used for analysisfor the microarray and TMA data was recurrence-free survival (RFS). Allstatistical analysis was carried out using the R programming language(version 2.15.0). Heatmaps were created using an online tool (availableon the world wide web at chibi.ubc.ca/matrix2png). Enrichment analysiswas carried out by calculating the number of unique ‘poor prognosis’genes present in the ‘core proliferation’ signature, compared to whatwould be expected across the genome (Observed/Expected). Unique genes inthe ‘poor prognosis’ signatures were n=61 for the MammaPrint signature,and n=207 for the Genomic Grade signature, and analysis was normalisedbased on the experimental platform used to derive the signature.

TMA Cohort

The tissue microarray (TMA) used in this study was derived from areference cohort of 512 consecutive invasive breast cancer casesdiagnosed at the Department of Pathology, Malmo University Hospital,Malmo, Sweden, between 1988 and 1992, and has been previously described(Svensson et al., 2005). In brief, the median age was 65 years (range27-96) and median follow-up time regarding disease-specific and overallsurvival was 11 years (range 0-17). Patients with recurrent disease andprevious systemic therapies were excluded, as well as a number ofmisclassified ductal carcimona in situ (DCIS) cases. Two hundred andsixty-three patients were dead at the last follow-up (December 2004), 90of which were classified as breast cancer-specific deaths. Tissue cores(1 mm) from areas representative of invasive cancer were extracted fromdonor blocks and arrayed in duplicate. This study has been approved bythe Ethics Committee at Lund University and Malmo University Hospital.

Immunohistochemistry

TMA slides were deparaffinised in xylene and rehydrated in descendinggradient alcohols. Heat-mediated antigen retrieval was performed using10 mM sodium citrate buffer (pH 6.0) in a PT module (LabVision, UK) for15 min at 95° C. The LabVision IHC kit (LabVision, UK) was used forstaining. Endogenous peroxidase activity was blocked by incubation with3% hydrogen peroxide for 10 min. Sections were blocked for 10 min in UVblocking agent and the relevant primary antibody was incubated for 1 hr.Sections were washed in phosphate buffered saline with 0.1% Tween 20(PBS-T), following which primary antibody enhancer was applied for 20min, and sections were washed in PBS-T. Sections were then incubatedwith HRP polymer for 15 min, washed in PBS-T and then developed for 10min using diaminobenzidine (DAB) solution (LabVision, UK). Allincubations and washing stages were carried out at room temperature. Thesections were counterstained in haematoxylin, dehydrated in alcohol andxylene and mounted using DPX mounting medium. As a negative control, theprimary antibody was substituted with PBS-T.

Primary antibodies used were HMGB2 (Abcam; 1:1500), UHRF1 (BDBiosciences; 1:1000), PTTG1 (Invitrogen; 1:500), FOXM1 (Santa Cruz, C20;1:300), and p16 (Clone JC8; 1:5000). TMA sections had been previouslybeen stained in the Ventana Benchmark (Ventana Medical Systems Inc, USA)using prediluted antibodies to ER (clone 6F11, Ventana), PR (clone 16,Ventana) and Her2 (Pathway CB-USA 760-2694), or in the Dako Techmate 500(Dako, Denmark) for Ki-67 (1:200, M7240, Dako).

TMA Analysis

Slides were scanned at 20× magnification using a ScanScope XT slidescanner (Aperio Technologies, CA). For manual scoring, staining of tumorcells was evaluated by a pathologist on the basis of intensity, on ascale of negative (0), weak (1), moderate (2) and strong (3); andpercentage, on a scale of 0-6 (0=0-1%; 1=1-10%; 2=10-25%: 3=25-50%;4=50-75%; 5=75-90%; 6=90-100%). Staining for the factors HMGB2 and UHRF1was predominantly nuclear, whereas PTTG1, FOXM1 and p16^(INK4A) stainedboth the nuclear and cytoplasmic compartments and were scoredaccordingly. For UHRF1, PTTG1 and p16^(INK4A), the percentage ofpositive tumor nuclei was the most significant variable in relation tooutcome and was used in all further analysis. For HMGB2, a modifiedAllred score (intensity plus percentage) was used and, for FOXM1, thepercentage of cytoplasmic positivity within tumor cells was the mostsignificant variable. For analysis of the four MTRs, a threshold forpositivity was applied independently for each variable, to create abinary score with low (0) and high (1) expression. For p16^(INK4A), the‘negative’ (0% positive cells) and ‘high’ (>50% positive cells)expression groups were combined and given a score of 1, and compared tothe ‘moderate’ group with a score of 0. To generate a combined MTR scoreat the protein level, the sum of the binary scores for all four MTRs wasgenerated. Tumors with high expression of >1 MTR were classified ashaving a high MTR score. To generate the combined 4MTR+p16^(INK4A) score(OncoMasTR IHC score), the binary 4MTR score was combined with thebinary p16^(INK4A) score, and divided into two groups with a thresholdof >2.

Results

Identification of a ‘Core Proliferation’ Gene Expression Signature.

The applicant set out to identify a set of ‘core proliferation’ genesthat are consistently highly expressed in actively growing cells in alineage-independent fashion. To do this, the applicant isolated humanmammary epithelial cells (HMECs) and mouse embryonic fibroblasts (MEFs)and passaged them towards cellular senescence, as characterised by anincrease in the levels of p16^(INK4A) (Zindy et al., 1997), and adecrease in the levels of the E2F target gene, EZH2 (Bracken et al.,2003) (FIG. 1A). The applicant next performed a genome-wide mRNAexpression analysis on proliferating and senescing HMEC and MEF culturesand identified four differentially expressed gene clusters (FIG. 1B).The expression changes of representative genes from each cluster werevalidated by quantitative RT-PCR (FIG. 1C). The Cluster 3 genes, whichwere down-regulated during serial passaging of HMEC cells, includedseveral genes involved in mammary epithelial cell-specific processes,such as the luminal cytokeratin KRT19 and the tight junction proteinCLDN3. This is consistent with the fact that the proportion of luminaland myoepithelial cells shifts during serial passaging of HMEC cells(Garbe et al., 2009). Therefore, the applicant reasoned that many of thegenes within Cluster 3 were down-regulated independently of theprogressive decrease in proliferation rate. Consistent with this, a geneontology analysis for each of the four gene clusters revealed a greaterenrichment of functional categories linked to cell cycle andproliferation in Cluster 4, compared to Cluster 3 (FIG. 1D). Therefore,the strategy to combine the expression changes of both serially passagedMEF and HMEC allowed the identification of a ‘core proliferation’ genesin mammary epithelial cells.

The applicant next wished to determine how enriched the Cluster 4 ‘coreproliferation’ genes were in two of the best known ‘breast cancer poorprognosis’ signatures, the MammaPrint 70-gene signature and the ‘GenomicGrade’ signature (Sotiriou et al., 2006; van 't Veer et al., 2002). Thisrevealed a significant enrichment of Cluster 4 genes, but not genes fromClusters 1-3, in both poor prognosis signatures (FIG. 1E), supportingthe, perhaps unsurprising, view that a major contributor to theprognostic power of these two signatures is their ability to simplymeasure tumor cell proliferation (Mosley and Keri, 2008; Wirapati etal., 2008).

Identification of Upstream Master Transcriptional Regulators (MTRs) ofthe ‘Core Proliferation’ Signature.

Interestingly, despite the ability of several established poorprognostic signatures to predict breast cancer outcome, there issurprisingly little overlap between the signatures themselves (Fan etal., 2006; Haibe-Kains et al., 2008). The applicant reasoned that theproliferative genes within these signatures, several of which are ‘coreproliferation’ genes in the analysis presented herein (FIG. 1E), may infact be just passengers, rather than drivers of tumour cellproliferation. Therefore, the applicant hypothesised that the upstreamtranscriptional regulators of the ‘core proliferation’ genes would bemore reliable predictors of breast cancer prognosis.

Considering the hierarchical nature of gene expression regulation, theapplicant wished to identify the key transcriptional regulators upstreamof the core proliferation signature. To identify the upstream mastertranscriptional regulators (MTRs) of the ‘core proliferation’ genes, abioinformatic approach called ARACNe was used (Carro et al., 2010;Margolin et al., 2006). This approach uses interaction networksconstructed from gene expression datasets to infer directtranscriptional interactions. ARACNe was applied to three publiclyavailable breast cancer gene-expression datasets (ExPO; Loi et al.,2007; van de Vijver et al., 2002) and predicted several upstream MTRs ofthe ‘core proliferation’ genes in breast cancer (FIG. 2A and Table 1).Among the top scoring MTRs were Forkhead Box M1 (FOXM1), ubiquitin-likePHD and RING finger 1 (UHRF1), Securin or Pituitary Tumour-TransformingGene 1 (PTTG1), E2F Transforming Factor 1 (E2F1), v-myb myeloblastosisviral oncogene homolog (avian)-like 2 (MYBL2) and High Mobility GroupBox 2 (HMGB2), which were relatively consistent across the threeindependent breast cancer datasets, supporting the idea that the MTRswould prove to be more reliable indicators of tumor cell proliferationthan their downstream target genes. Four additional genes were alsoidentified consistently across datasets as being upstream of the ‘coreproliferation’ genes. These are ATAD2, E2F8, ZNF367 and TCF19.

TABLE 1 Top ranking master transcriptional regulators of the indicatedexpression signatures as predicted by ARACNe Core Proliferation PoorPrognosis Genomic grade Rank signature signature signature 1 FOXM1 PTTG1PTTG1 2 PTTG1 FOXM1 FOXM1 3 UHRF1 UHRF1 UHRF1 4 MYBL2 ATAD2 MYBL2 5HMGB2 MYBL2 ATAD2 6 ATAD2 ZNF367 HMGB2 7 E2F1 HMGB2 ZBTB20 8 E2F8 TCF19E2F1 9 ZNF367 E2F8 E2F8 10 TCF19 E2F1 ZNF367

The applicant next wished to determine if some of the MTRs directly bindto the promoters of Cluster 4, ‘core proliferation’ genes, as predicted.Chromatin immunoprecipitations (ChIPs) followed by quantitative RealTime PCR (qPCR) confirmed the direct binding of four of the MTRs (FOXM1,MYBL2, E2F1 and HMGB2) to the promoters of ‘core proliferation’ genes inHMEC-Tert cells (FIG. 2B). To gain a broader view on MTR bindingthroughout the genome, ChIP followed by high-throughput sequencing(ChIP-seq) was performed on HMEC-Tert cells for E2F1, MYBL2 and FOXM1.This revealed that all three MTRs primarily associate with the promotersof the Cluster 4, ‘core proliferation’ genes, and to a lesser extent,some Cluster 3 genes (FIG. 2C). The ChIP-seq tracks of threerepresentative genes show peaks depicting binding of E2F1, MYBL2 andFOXM1 on the CCNB1, UBE2C and CENPA gene promoters (FIG. 2D), but not onthe promoter of a gene not expressed in HMECs, KRT2. The applicant wasnot able to investigate the genome-wide binding patterns of PTTG1 orUHRF1 due to the lack of suitable high quality ChIP-grade antibodies.However, the fact that PTTG1 has been reported to have a role in thetranscriptional activation of cell cycle genes, supports the ARACNepredictions (Tong and Eigler, 2009; Tong et al., 2007). On the otherhand, UHRF1 is generally considered to be a transcriptional repressor,being required for the maintenance of DNA methylation during celldivision (Bostick et al., 2007). Therefore, UHRF1 is unlikely todirectly regulate core proliferation genes, and is more likely to be aco-regulated proliferative gene. Supporting this possibility, E2F1,MYBL2, and FOXM1 also bind the promoter of the UHRF1 gene in HMEC cells.

In parallel with the identification of these MTRs, the Applicant alsocarried out unbiased survival analysis of 565 node-negative patientsfrom four independent breast cancer gene expression datasets (Buffa etal., 2011; Ivshina et al., 2006; Loi et al., 2007; van de Vijver et al.,2002), in order to identify the genes associated with patient survivalin ranked order (Table 2). Strikingly, this analysis identified severalof the proliferation MTRs as among the top 20 genes associated withbreast cancer outcome in these node-negative patients, with several ofthese proliferation MTRs scoring higher than conventional clinicalbiomarkers (ER, PR, Ki67) or genes incorporated into the Oncotype Dxassay (BIRC5, CCNB1, BCL2, CTSL2). This result illustrated the power ofthese MTRs as prognostic biomarkers, and inspired us to investigate themfurther.

TABLE 2 Unbiased survival analysis of all genes across four breastcancer datasets (Van de Vijver et al, Loi et al, Ivshina et al, Buffa etal.,). Gene expression values were divided at the median, analysed inrelation to overall survival using the log rank test, and ranked inorder of prognostic power. Rank Gene Function 1 PRC1 Cell cycle 2 UHRF1Proliferation MTR 3 ZWINT Cell cycle 4 IGBP1 Signal transduction 5 RPL29Ribosomal protein 6 CCNB2 Proliferation 7 TRIP13 DNA repair 8 CDC45LCell cycle 9 TROAP Cell adhesion 10 TACC3 Proliferation 11 LRP2Lipoprotein/Hormone signalling/Stress response 12 MAD2L1 Cell cycle 13BLM DNA replication and repair 14 CDKN3 Cell cycle 15 SEC14L2Cholesterol Biosynthesis 16 MYBL2 Proliferation MTR (and Oncotype Dx) 17BIRC5 Oncotype Dx ® (Anti-apoptosis) 18 PTTG1 Proliferation MTR 19 H2AFZChromatin remodeling 20 TK1 DNA replication 21 FBXO5 Ubiquitin pathway22 EIF2C2 RNAi pathway 23 EBP Cholesterol Biosynthesis 24 PLP2Endoplasmic reticulum protein 25 EZH2 Proliferation/Polycomb protein 26FOXM1 Proliferation MTR 27 PDZK1 Scaffolding protein/Cholesterolmetabolism 28 FEN1 DNA repair 29 TXNRD1 Oxidative stress 30 COL4A1Basement membrane component 31 STC2 Calcium homeostasis/Estrogensignalling 32 GPR56 Cell signalling 33 SQLE Sterol Biosynthesis 34 EXO1DNA repair 35 YWHAZ Anti-apoptosis 36 GATA3 Hormone Response 37 KIF4ACell cycle 38 ADM Hormone sigalling 39 CREBL2 Cell cycle 40 TTKProliferation 41 BUB1 Cell cycle/Apoptosis 42 CTPS DNA synthesis 43CHST3 Cell migration/Wound response 44 CAMLG Apoptosis/Calciumhomeostasis 45 PSMD1 Proteasome component 46 KIF13B DNA damage pathway47 NRM Nuclear membrane protein 48 STXBP2 Vesicle trafficking 49 GALTGlycoprotein metabolism 50 GPI Glycogen metabolism/Angiogenesis 51 POLD1DNA replication 52 RRM2 DNA replication 53 MYBProliferation/Differentiation 54 CDC20 Cell cycle 55 SERPINH1Inflammatory response/Protolysis 56 SERPINA3 Proteolysis 57 HMMR Cellmotility 58 PDCD4 Invasion/Apoptosis 59 PGK1 Glucose metabolism 60 RQCD1Cell differentiation 61 NDRG1 Stress response/Apoptosis 62 SLU7 mRNAsplicing 63 ESR1 Oncotype Dx ® (Hormone Response) 64 SPARCL1 Cellmigration/Invasion 65 NME5 Anti-apoptosis 66 BTG2 Anti-proliferative 67WDR5 Histone modification 68 HMGCL Ketogenesis 69 SERPINE1 Cellmigration/invasion 70 BTN2A1 Lipid metabolism 71 CELSR2 Cell-celladhesion/signalling 72 PKM2 Glucose metabolism 73 ORC1L DNA replication74 FANCA DNA repair 75 FLT3 Angiogenesis 76 TYMS 77 SIRT1 78 GARS 79XPOT 80 FUT8 Protein glycosylation 81 BTD 82 LZTFL1 83 STIP1 84 ME1 85UCP2 86 RPL14 87 NP 88 CIRBP 89 ORC6L 90 PSMD7 91 CCNE2 92 CENPA 93CDC25B 94 E2F1 Proliferation MTR 95 CCNB1 Proliferation (Oncotype Dx ®)96 H2AFX 97 RAD54L 98 ADAMTS7 99 LEPR 100 KIAA1609 101 KIAA1407 102CCNA2 Cell cycle 103 PFKL 104 KIAA0999 105 SLC23A2 106 FUCA1 107 RFC2108 CCNI 109 NEK2 110 HS3ST1 111 DYSF 112 AGTR1 113 VAV3 114 PDE6B 115POLA2 116 ATP5G3 117 KIAA0831 118 PTMA 119 GSTM3 120 PHB 121 MAP4K4 122PGR Oncotype Dx ® (Hormone Response) 123 BCL2 Oncotype Dx ®(Anti-apoptosis) 124 IGFBP4 125 CENPE 126 CYC1 127 CDO1 128 MYCBP 129SKP2 130 RAB3D 131 DHCR7 132 KIAA1324 133 ATP11A 134 BECN1 135 HDGF 136PCYT1A 137 TNNC1 138 CENPF 139 ADCY1 ATP metabolism 140 MKI67 OncotypeDx ® (Proliferation) 141 KIAA0101 142 KCNN3 143 SLC19A1 144 EPHA4 Celladhesion/signalling/migration/invasion 145 CDC25C 146 NFATC1 147 PDE5A148 ABCF1 149 CKS2 150 PRRG2 CalciumVitamin K signalling 151 CLDN4 Celladhesion 152 GTSE1 153 RAI2 154 PRLR Hormone signalling 155 SEMA7A 156CPT1A 157 PDHA1 158 RAB27B 159 MCM2 160 FLNB 161 SLC2A3 Glucosetransport/metabolism 162 IMPDH2 163 HMGB2 Proliferation MTR 164 HOXB13Homeobox protein 165 NFRKB 166 RPS6KA5 167 CRIP2 168 BTF3 169 MAGED1 170NAPG 171 ASNS 172 PTTG2 173 TPST1 Wound response 174 RPLP1 175 GLTSCR2176 PLA2R1 177 POLQ 178 CSTB 179 CALU Calcium-dependent signalling 180PPARD 181 TXN 182 NAT1 183 MYO7A 184 EIF4G1 185 SHMT2 186 PTDSS1 187LHX2 188 PLA2G10 189 ANLN 190 ATP5J 191 POLR2D 192 SERF1A 193 EPHB4 194CDC23 195 PTPN14 196 PEX12 197 PPP1R11 198 CSPG5 199 DONSON 200 CTSL2Oncotype Dx ® (Invasion) (italics = MTRs; bold = conventional clinicalbiomarkers) OncoMasTR pathway genes include: IGBP1; LRP2; PDZK1; TXNRD1;GATA3; ADM; CAMLG; SERPINA3; NDRG1; SERPINE1; FLT3; FUT8; ADCY1; EPHA4;PRRG2; CLDN4; PRLR; SLC2A3; HOXB13; TPST1; and CALU.

Proliferative MTRs are Excellent Predictors of Breast Cancer Prognosison the RNA and Protein Levels.

Next, the potential clinical significance of the MTRs as prognosticmarkers in breast cancer was explored. The applicant began by performingan unbiased ARACNe analysis of the MammaPrint and Genomic Gradesignatures, both of which have been shown to predict clinical outcome inbreast cancer patients (Sotiriou et al., 2006; van 't Veer et al.,2002). Remarkably, across the three independent datasets analysed (ExPO;Loi et al., 2007; van de Vijver et al., 2002), FOXM1, E2F1, MYBL2,UHRF1, PTTG1, HMGB2, ATAD2, E2F8, ZNF367, and TCF19 were predicted to beamong the top upstream regulators of both ‘poor prognosis’ signatures(FIG. 3A and Table 1). This suggests that these MTRs directly regulatethe expression of many genes within both the MammaPrint and GenomicGrade prognostic signatures.

The applicant next wished to explore the possibility that the MTRs maythemselves be reliable predictors of poor prognosis. The association ofeach individual MTR with patient survival was examined in a combineddataset of three published microarray studies representing thegenome-wide mRNA expression of 457 lymph node-negative breast tumoursuntreated by chemotherapy (Loi et al., 2007; Miller et al., 2005; van deVijver et al., 2002). This revealed that high mRNA expression levels ofany of FOXM1, E2F1, MYBL2, UHRF1, PTTG1, HMGB2 in breast tumours wassignificantly associated with reduced recurrence-free survival time, anda combination of all six MTRs was more powerful at stratifying thepatients compared to any MTR alone (FIG. 3B). Significantly, usingeither a low/high or a low/moderate/high categorisation strategy, thesix MTR combination was better at predicting recurrence-free survivalthan the established proliferation marker Ki67 (FIG. 3B). These six MTRsnow form the ‘core’ panel of the method or assay of the presentinvention, also called the OncoMasTR assay. High mRNA expression levelsof ATAD2 and TCF19 in breast tumours was also significantly associatedwith reduced recurrence-free survival time in this cohort (FIG. 9).Expression information was not available in this cohort for E2F8 andZNF367.

Next, the protein levels of the MTRs were examined in an independentbreast cancer patient cohort via immunohistochemistry (IHC). Antibodieswere screened for all 6 MTRs and four identified that specificallyrecognised FOXM1, HMGB2, PTTG1 and UHRF1. Tissue microarrays (TMAs)representing 512 invasive breast tumours were evaluated for the proteinlevels of each of these MTRs (FIG. 3C). The stained TMAs were manuallyscored and the results analysed in relation to recurrence-free survivalfor the 430 tumours with information on all four MTRs (FIG. 3D). EachMTR was individually associated with poor prognosis, and the combinationof all four MTRs was more powerful at stratifying the patients inrelation to survival, compared to existing prognostic indicators such asKi67 or the St. Gallen criteria, a prognostic index based on age, nodalstatus, tumour size, ER/PR status and tumour grade (Goldhirsch et al.,2001) (FIG. 3D). The results from this Kaplan-Meier analysis were alsorepresented in a heat-map format to indicate the strength of theassociation with recurrence-free survival (FIG. 3E). To the knowledge ofthe inventors, this heat-map arrangement has not been previously used topresent large-scale survival analysis, and provides an intuitive way ofdetermining the best prognostic combination in any particular dataset.

To further refine the prediction method of the claimed invention andcomplement the approach taken by the Applicant, the other crucialpathways, besides proliferation control, involved in breast cancerprogression were taken into account. Additional genes from the unbiasedanalysis of four independent breast cancer datasets (described above andin Table 2) were selected, which strongly correlate with survival, andrepresent other aspects of tumour progression as distinct fromproliferation, such as migration/invasion, apoptosis and hormonesignalling pathways (Table 3). When combined with the proliferationMTRs, these genes add a further layer of information, and increase thepredictive power of the gene combination even further. These genes formthe basis of the OncoMasTR pathway panel which, when combined with theOncoMasTR core genes, further improve the prognostic power of themethod.

TABLE 3 Summary of OncoMasTR Core and Pathway gene panels OncoMasTR CorePanel OncoMasTR Pathway panel Hormone/ Migration/ Growth Factor OtherProliferation Invasion Apoptosis signalling function UHRF1 EPHA4 BIRC5CAMLG IGBP1 FOXM1 HOXB13 BCL2 PRLR FUT8 MYBL2 CLDN4 TXNRD1 ADM CALUPTTG1 SERPINE1 NDRG1 PRRG2 ADCY1 E2F1 HMGB2 Estrogen Inflammation/Metabolic signalling Wound response Angiogenesis pathways GATA3 TPST1FLT3 SLC2A3 PDZK1 SERPINA3 LRP2

Disruption of Cellular Senescence Pathways can be Inferred Using aCombination of MTRs and p16^(INK4A) Levels and is a Strong Predictor ofPoor Outcome in Breast Cancer

The applicant next wished to examine if the levels of p16^(INK4A), apotential proxy for bypass of the cellular senescence checkpoint incancer, could add to the prognostic power of the MTRs. First, to confirmthat deregulated CDKN2A mRNA levels correlated with genetic perturbationof the cellular senescence checkpoint, The Cancer Genome Atlas (TCGA)breast cancer dataset (Cancer Genome Atlas, 2012) was analysed, andfound that high levels of CDKN2A mRNA levels correlated with deletion ofRB1, as previously reported in other studies (Hara et al., 1996; Kotakeet al., 2007; Li et al., 1994; Tam et al., 1994), while deletion ofCDKN2A correlated with decreased mRNA levels (FIG. 4A). Strikingly,moderate mRNA levels of INK4A were found to correlate with improvedrecurrence-free survival in 457 lymph node-negative breast cancerpatients, while either very low or very high levels correlated withshorter recurrence-free survival (Loi et al., 2007; Miller et al., 2005;van de Vijver et al., 2002) (FIG. 4B). The applicant next performed IHCfor the p16^(INK4A) protein on the same breast cancer TMAs usedpreviously (FIG. 4C). This confirmed that either very high or very lowp16^(INK4A) protein levels also correlated with both shorter recurrencefree and breast cancer-specific survival, whereas moderate levelscorrelated with extended survival (FIG. 4D-4E).

Based on these observations, the applicant reasoned that the breastcancers with either very high or very low p16^(INK4A) protein levels hadbypassed the cellular senescence checkpoint, and this could potentiallyexplain their poor prognosis. The breast cancers with low p16^(INK4A)protein levels were most likely to have a deletion in the INK4A genelocus, while those with aberrantly high levels likely had mutations inthe INK4A gene or deregulation of downstream E2F-pRB pathway memberssuch as Cyclin D1 or pRB. In contrast, the tumors with moderateexpression of INK4A were most likely enriched in cells that had notbypassed the cellular senescence checkpoint and, therefore, had a morefavourable prognosis.

Previous studies of p16^(INK4A) expression in relation to breast cancerprognosis have reported conflicting results—while p16^(INK4A) was foundto be associated with poor prognosis in some cohorts (Hui et al., 2000;Milde-Langosch et al., 2001), other studies showed an association withimproved outcome (Peurala et al., 2013). These studies have generallysplit expression values into two groups, low/negative and high, foranalysis. However, based on what is known of the biology of p16^(INK4A)and the p16-Rb pathway in cancer, the Applicant proposes that the bestapproach may be to examine p16^(INK4A) expression in three groups,low/negative, moderate and high expression. This may separate tumorswhich are likely to have deleted or inactivated p16^(INK4A) (lowexpressers) and those which have aberrantly high levels of p16^(INK4A)and are likely to have a dysregulated p16-Rb pathway (high expressers)from the tumors with a functioning senescence response (moderateexpressers).

A Combination of Measuring Proliferative MTRs and p16^(INK4A) Levels(OncoMasTR Score) Outperforms Currently Used Approaches for PredictingBreast Cancer Prognosis.

The prognostic ability of a combination of p16^(INK4A) and theproliferative MTRs were evaluated next. To do this, a score encompassingboth proliferative MTRs and p16^(INK4A) expression was developed, termedthe ‘OncoMasTR RNA score’, and compared with estimates of other leadingmulti-gene prognostic assays (FIG. 5A). This revealed that the OncoMasTRRNA score compared favourably to surrogate estimations of theMammaPrint™ and OncotypeDx® signatures, using low/high categories forcomparison with MammaPrint™, and low/moderate/high categories forcomparison with Oncotype Dx®. In order to further demonstrate theprognostic capability of the OncoMasTR RNA score, the applicant analysedeach individual dataset and the combined dataset, and represented theresults in a heat-map format (FIG. 5B). This extended analysis revealedthat, while the MammaPrint™ 70-gene signature performed best in thedataset which included samples used in its derivation (van 't Veer etal., 2002; van de Vijver et al., 2002), the OncoMasTR RNA scoreoutperformed estimates of both the MammaPrint™ and Oncotype Dx® assaysoverall when all three datasets were combined. Next, to validate theseobservations at the protein level, the applicant combined thep16^(INK4A) protein and the IHC-based 4-MTR panel, called the ‘OncoMasTRIHC score’, and tested this combination in all patients and in lymphnode-negative patients, in relation to both recurrence-free survival(FIG. 5C) and breast cancer-specific survival (FIG. 5D). This revealedthat when p16^(INK4A) is added to the IHC-based MTR panel, thecombination of high levels of proliferative MTR proteins and either lowor aberrantly high p16^(INK4A) protein was strongly associated with poorprognosis, and there was a striking improvement in the ability topredict patient survival in comparison to the four MTRs withoutp16^(INK4A), either on all patients (FIG. 5C) or on a lymphnode-negative sub-cohort (FIG. 5D).

The OncoMasTR RNA Score Outperforms Surrogate Estimates of MammaPrint™and Oncotype Dx® in ER-Positive Patients

In order to further evaluate the potential clinical utility of theOncoMasTR RNA score, its prognostic power was examined in 366ER-positive, lymph node-negative patients, which reflects the inclusioncriteria for the Oncotype Dx® assay. The OncoMasTR RNA scoreoutperformed surrogate estimates of both the MammaPrint™ (low/highgroups), and Oncotype Dx® (low/mod/high groups) assays in both theentire cohort (FIG. 6A), and lymph node-negative patient cohort (FIG.6B). The OncoMasTR RNA score was also assessed using a Taqman® qRT-PCRapproach in 151 ER-positive, lymph node-negative patients using DMFS asan endpoint, matched to the cohort used for IHC validation (FIG. 7).This demonstrated that the OncoMasTR RNA score, when measured by Taqman®qRT-PCR analysis, showed analogous performance to the microarray-basedanalysis. Furthermore, the OncoMasTR IHC score also demonstrated utilityin this group of patients, using either recurrence-free survival, ordistant metastasis-free survival (FIG. 8) as an endpoint.

The OncoMasTR Score has Independent Prognostic Value in all Patients andLymph Node-Negative Patients

Next, in order to determine if the MTR and INK4A/p16^(INK4A) combinationcan provide additional prognostic information independent of standardclinicopathological variables, the applicant performed multivariateanalysis using Cox proportional hazards models. The OncoMasTR score wasfound to contribute added prognostic information to a standardclinicopathological variable model, in terms of recurrence-freesurvival, at both mRNA (Table 4) and protein (Table 5) levels. This wasalso observed in the lymph node-negative patient cohort. The addedprognostic value of the OncoMasTR score on top of the standard clinicalmodel is superior to all other prognostic indicators, including Ki67,the 70-gene signature (MammaPrint™) and the 21-gene signature (OncotypeDx®). Furthermore, the OncoMasTR RNA score was found to providesignificant additional prognostic information to a model comprising thestandard clinical variables together with the Oncotype Dx® surrogateestimation.

TABLE 4 Multi-variate Cox regression analysis using a standard clinicalvariable model* in the combined microarray datasets All patients Nodenegative patients (n = 567) (n = 410) Variable Chi2** p-value Chi2p-value Lo/ FOXM1 24.14 <0.001 26.59 <0.001 Med/ E2F1 25.28 <0.001 15.56<0.001 Hi HMGB2 10.89 <0.001 7.47 0.006 MYBL2 25.43 <0.001 15.91 <0.001PTTG1 12.37 <0.001 10.16 0.001 UHRF1 22.71 <0.001 17.61 <0.001 CDKNA2.23 0.135 13.82 <0.001 6MTR 33.80 <0.001 20.27 <0.001 OncoMasTR 43.87<0.001 44.04 <0.001 RNA score 21 gene 29.02 <0.001 38.03 <0.001 Ki678.30 0.004 7.45 0.006 Lo/ 6MTR 23.82 <0.001 29.32 <0.001 Hi OncoMasTR29.62 <0.001 32.20 <0.001 RNA score 70 gene 30.20 <0.001 28.88 <0.001Ki67 5.52 0.018 8.99 0.003 *Clinical variables used: Age (>=50 years),Nodal status, Tumor size (>=2 cm), Tumor grade (>1), treatment(endocrine therapy) and ER status. **Added prognostic value of eachvariable, represented by change in the Chi2 value from the model of onlyclinical variables to the model of clinical variable + marker in thethree combined microarray datasets. Recurrence-free survival was used asthe endpoint for this analysis.

TABLE 5 Multi-variate Cox regression analysis using a standard clinicalvariable model* in tissue microarrays All patients Node negativepatients (n = 272) (n = 171) Variable Chi2** p-value Chi2 p-value Lo/FOXM1 1.60 0.207 0.49 0.485 Hi HMGB2 0.05 0.819 2.53 0.112 PTTG1 4.030.044 0.17 0.677 UHRF1 4.53 0.033 0.77 0.379 p16 6.73 0.009 7.23 0.007 4MTRs 12.24 <0.001 0.28 0.597 OncoMasTR IHC score 24.86 <0.001 7.28 0.007Ki67 5.23 0.022 3.42 0.064 *Clinical variables used: Age (>=50 years),Nodal status, Tumor size (>=2 cm), tumor grade (>1), treatment(chemotherapy, endocrine therapy, radiotherapy), ER and HER2 status.**Added prognostic value of each variable, represented by change in theChi2 value from the model of only clinical variables to the model ofclinical variable + marker in the tissue microarray datasets.Recurrence-free survival was used as the endpoint for this analysis.

Prognostic Power in a Prostate Cancer Cohort

This current project describes the validation of the OncoMasTR panel asa breast cancer prognostic on independent cohorts, however the panel mayalso be used for other cancer types such as those listed above. Forexample, a publically available prostate cancer transcriptomic datasetwas analysed (Taylor et al., 2010), revealing that the OncoMasTR panelshowed prognostic capability in terms of metastasis-free survival inthis cancer type (see FIG. 10). Prostate cancer patients with highexpression of the 6 MTR panel (FOXM1, E2F1, MYBL2, UHRF1, PTTG1, HMGB2)were found to have a poor outcome in comparison to patients with lowexpression of these genes.

A method of prediction based on the expression of these MTRs andp16^(INK4A) will be capable of addressing the unmet need of early stagebreast cancer patients, and provide them with the necessary tools tomake better informed treatment decisions. The addition of additionalpathway genes, or novel MTRs such as ATAD2, E2F8, ZNF367 and TCF19, someof which have been demonstrated to predict poor prognosis in breastcancer patients (FIG. 9); may also improve the prognostic capability ofthis assay even further. Such a test will improve on what is currentlyavailable based on the fact that each of these MTRs is upstream of manygenes involved in breast cancer proliferation and thus, by measuringthese MTRs, one is effectively measuring the status of a much larger‘proliferation signature’. The predictive power of this panel ofproliferation MTRs has been augmented by the addition of the senescenceregulator p16^(INK4A). By combining these ‘core’ genes with selected‘pathway’ genes, one can thoroughly dissect the molecular complexitiesof breast cancer, and accurately determine the likelihood of recurrence.

The prognostic potential of these 10 MTRs, in combination withp16^(INK4A), were subsequently individually analysed using BreastMark(Madden, S. F. et al. BreastMark: an integrated approach to miningpublicly available transcriptomic datasets relating to breast canceroutcome. Breast Cancer Res 15, R52, doi: 10.1186/bcr3444 (2013)), anintegrated approach for performing cross-dataset survival analysis inbreast cancer (Table 6). This algorithm integrates gene expression andsurvival data from 26 datasets on 12 different microarray platformscorresponding to approximately 17,000 genes in up to 4,738 samples. Thebreakdown of the individual clinical information available with eachdataset is described in detail in the original manuscript, along withthe methods used for analysing/normalising the gene expression data.Cross-dataset survival analysis across multiple disparate microarrayplatforms is facilitated by gene centring the data to remove probespecific information and dichotomising the samples within each datasetbefore combining them to perform a global pooled survival analysis. Inthe analysis presented herein, disease free survival (DFS) was chosen asthe survival endpoint and median gene expression was used to dichotomisethe data.

There are over a 1,000 combinations of MTRs with four or more genes thatcan be chosen from the list of 10 MTRs described herein, each of whichcan be combined and assessed for their prognostic potential. In order toidentify the optimal combination of these MTRs, BreastMark was adaptedin the following way. For each combination of MTRs, the processeddatasets from BreastMark were taken and, within each dataset, theexpression data of each MTR was divided at the median into two groups.Once the samples have been dichotomised, the gene expression data is nolonger used, allowing comparisons across different datasets/platforms.To generate a combined master transcriptional regulator (MTR) score, thegene expression values for each of the MTR in a particular combinationwere divided at the median, given a score of 1 or 2 based on theexpression level. This results in each sample in a particular datasetgetting a MTR score based on the sum of its individual MTR scores. Forexample, if a particular MTR combination contained 6 genes, and eachgene in a particular sample was expressed at a level below the medianexpression of that gene in that dataset, the MTR score would be 6, thesum of the score of 1 for each of the 6 MTR. This results in a range ofMTR scores between 6 (all MTRs are lowly expressed) and 12 (all MTRs arehighly expressed), which can then be dichotomised based on the medianMTR score for that dataset and combined with the DFS information toidentify if this combination of MTRs is prognostic (a significantp-value) and how prognostic it is (the hazard ratio).

The top 100 combination of MTRs can be seen in the forest plot in FIG.11, and the individual Kaplan-Meier plots for the top 24 combinationscan be seen in FIG. 12. The samples were ranked based on the size of thehazard ratio once significance had been established (adjusting formultiple testing using the Benjamini and Hochberg method (Benjamini, Y.,Drai, D., Elmer, G., Kafkafi, N. & Golani, I. Controlling the falsediscovery rate in behavior genetics research. Behavioural brain research125, 279-284 (2001)). It should be noted that the sample sizes varydepending on the combination of MTRs used as not all MTRs are present inall 26 BreastMark datasets, e.g. ZNF367 is only present in four datasetstotalling 295 samples.

TABLE 6 Individual breast cancer survival analysis of the top ten MasterTranscriptional Regulators identified by ARACNe, using the BreastMarkalgorithm. Transcription Entrez Sample Factor Gene ID Hazard RatioP-value Number ATAD2 29028 1.378 (1.224-1.552) 1.03E−07 2576 E2F1 18691.301 (1.15-1.472)  2.92E−05 2357 E2F8 79733 1.375 (1.214-1.558)4.74E−07 2281 FOXM1 2305 1.578 (1.392-1.788) 5.45E−13 2357 HMGB2 31481.271 (1.122-1.439) 0.0001493 2357 MYBL2 4605 1.506 (1.339-1.694)7.08E−12 2652 PTTG1 9232 1.586 (1.402-1.794) 1.25E−13 2437 TCF19 6941 1.27 (1.097-1.471) 0.00136 1378 UHRF1 29128 1.318 (1.144-1.52) 0.0001328 1533 ZNF367 195828  1.08 (0.8274-1.41) 0.571 295

Based on the mechanistic data underpinning the OncoMasTR panel, theapplicants also believe the predictive power of the panel will have acapacity in predicting response to CDK4/6 inhibitors such aspalbociclib. Palbociclib is an orally active, highly selective inhibitorof the cyclin-dependent kinases CDK4/6, which was initially assessed asa combination therapy with letrozole in advanced ER+Her2+ breast cancer,in the PALOMA-1 trial (Richard S. Finn, 2014). Results from this trialhave shown that the addition of palbociclib to a standard regimenextends survival by 10 months, which is a very promising result in theselate-stage patients. Based on the mechanistic data underpinningOncoMasTR, the Applicant believes that it is likely to have predictiveutility in terms of response to this novel therapy.

Calculating the MTR10+CDKN2A Signature Score in Pablociclib Treated CellLines

Pablociclib is an inhibitor of cyclin D kinases and its effects on humanbreast cancer cell lines were examined previously by Finn et al.Briefly, 47 human cell lines, representing the molecular subtypes ofbreast cancer, were treated with pablociclib and their gene expressionprofiles, along their IC50 values, were calculated. The gene expressiondata was downloaded from the Gene Expression Omnibus for the 47 celllines, along with the accompanying IC50 data (accession numberGSE18496). The gene expression data for the 10 MTRs described here wassplit on a gene by gene basis using median expression across all celllines as a cut-off. Those cell lines with greater or lower than medianexpression of a gene were given a value of 2 or 1 for that gene,respectively. This was repeated for each of the ten genes. Theexpression of CDKN2A across the cell lines was split equally in three,those cell lines with high or low expression were given a value of 2 andthose with an intermediate expression level were given a value of 1. Ascore was then calculated for each cell line by summing the individualgene scores. FIG. 13 shows a plot of IC50 values versus the signaturescore (correlation co-efficient=0.319, p-value=0.03). The significantp-value from the in vitro data suggests that the MTRs can providepredictive value in respect to patients receiving CDK4/6 inhibitors totreat cancer.

In the specification the terms “comprise, comprises, comprised andcomprising” or any variation thereof and the terms “include, includes,included and including” or any variation thereof are considered to betotally interchangeable and they should all be afforded the widestpossible interpretation and vice versa.

The invention is not limited to the embodiments hereinbefore describedbut may be varied in both construction and detail.

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1.-23. (canceled)
 24. A method of treating cancer in a patient in needthereof, the method comprising: assaying a cancer sample from thepatient for positive expression of at least FOXM1, PTTG1, and ZNF367;detecting positive expression of at least FOXM1; PTTG1; and ZNF367; andadministering a neoadjuvant or an adjuvant therapy or combination ofboth.
 25. The method according to claim 24, wherein the neoadjuvanttherapy and adjuvant therapy is an agent selected from the groupconsisting of: trastuzumab, lapatinib, neratinib, afatinib, pertuzumab,CDK4/6 inhibitors, cyclophosphamide, methotrexate, 5-fluorouracil,gemcitabine, adriamycin (doxorubicin), epirubucin, docetaxel,paclitaxel, capecitabine, and tamoxifen.
 26. The method according toclaim 24, the method further comprising the step of assaying for theexpression of p16^(INK4A) gene or a protein encoded by said gene. 27.The method according to claim 24, further comprising assaying the cancersample from the patient for positive expression of UHRF1, MYBL2, E2F8,HMGB2, ATAD2, E2F1, or TCF19.
 28. The method according to claim 24,wherein the cancer is selected from the group consisting of:node-negative, ER-positive breast cancer; early stage, node positivebreast cancer; multiple myeloma, prostate cancer, glioblastoma,lymphoma, fibrosarcoma; myxosarcoma; liposarcoma; chondrosarcoma;osteogenic sarcoma; chordoma; angiosarcoma; endotheliosarcoma;lymphangiosarcoma; lymphangioendotheliosarcoma; synovioma; mesothelioma;Ewing's tumour; leiomyosarcoma; rhabdomyosarcoma; colon carcinoma;pancreatic cancer; breast cancer; ovarian cancer; squamous cellcarcinoma; basal cell carcinoma; adenocarcinoma; sweat gland carcinoma;sebaceous gland carcinoma; papillary carcinoma; papillaryadenocarcinomas; cystadenocarcinoma; medullary carcinoma; bronchogeniccarcinoma; renal cell carcinoma; hepatoma; bile duct carcinoma;choriocarcinoma; seminoma; embryonal carcinoma; Wilms' tumour; cervicalcancer; uterine cancer; testicular tumour; lung carcinoma; small celllung carcinoma; bladder carcinoma; epithelial carcinoma; glioma;astrocytoma; medulloblastoma; craniopharyngioma; ependymoma; pinealoma;hemangioblastoma; acoustic neuroma; oligodendroglioma; meningioma;melanoma; retinoblastoma; and leukemia.
 29. A method of treating cancerin a subject in need thereof, the method comprising: being providedinformation comprising an indication of positive expression of at leastFOXM1, PTTG1, and ZNF367 in a cancer sample from a subject; and thenadministering a neoadjuvant or an adjuvant therapy or combination ofboth to the subject.
 30. The method according to claim 29, wherein theneoadjuvant therapy and adjuvant therapy is an agent selected from thegroup consisting of: trastuzumab, lapatinib, neratinib, afatinib,pertuzumab, CDK4/6 inhibitors, cyclophosphamide, methotrexate,5-fluorouracil, gemcitabine, adriamycin (doxorubicin), epirubucin,docetaxel, paclitaxel, capecitabine, and tamoxifen.
 31. The methodaccording to claim 29, wherein the subject is further determined to havedysregulated expression of p16^(INK4A), in combination with positiveexpression of the at least three genes.
 32. The method according toclaim 29, wherein the patient is further determined to have positiveexpression of UHRF1, MYBL2, E2F8, HMGB2, ATAD2, E2F1, or TCF19.
 33. Themethod according to claim 29, wherein the cancer is selected from thegroup consisting of: node-negative, ER-positive breast cancer; earlystage, node positive breast cancer; multiple myeloma, prostate cancer,glioblastoma, lymphoma, fibrosarcoma; myxosarcoma; liposarcoma;chondrosarcoma; osteogenic sarcoma; chordoma; angiosarcoma;endotheliosarcoma; lymphangiosarcoma; lymphangioendotheliosarcoma;synovioma; mesothelioma; Ewing's tumour; leiomyosarcoma;rhabdomyosarcoma; colon carcinoma; pancreatic cancer; breast cancer;ovarian cancer; squamous cell carcinoma; basal cell carcinoma;adenocarcinoma; sweat gland carcinoma; sebaceous gland carcinoma;papillary carcinoma; papillary adenocarcinomas; cystadenocarcinoma;medullary carcinoma; bronchogenic carcinoma; renal cell carcinoma;hepatoma; bile duct carcinoma; choriocarcinoma; seminoma; embryonalcarcinoma; Wilms' tumour; cervical cancer; uterine cancer; testiculartumour; lung carcinoma; small cell lung carcinoma; bladder carcinoma;epithelial carcinoma; glioma; astrocytoma; medulloblastoma;craniopharyngioma; ependymoma; pinealoma; hemangioblastoma; acousticneuroma; oligodendroglioma; meningioma; melanoma; retinoblastoma; andleukemias.
 34. A method of treating cancer in a subject in need thereof,the method comprising: assaying a sample from the subject prior toreceiving a neoadjuvant or an adjuvant therapy, or combination of both,for positive expression of at least FOXM1, PTTG1, and ZNF367; assaying asample from the subject after receiving the neoadjuvant or the adjuvanttherapy, or combination of both, for positive expression of at leastFOXM1, PTTG1, and ZNF367; continuing to administer the neoadjuvant orthe adjuvant therapy, or the combination of both, when detectingpositive expression of at least FOXM1; PTTG1; and ZNF367 at levels that,when combined, are lower when compared to the levels of expression fromthe sample assayed prior to receiving the neoadjuvant or the adjuvanttherapy, or combination of both; discontinuing to administer theneoadjuvant or the adjuvant therapy, or the combination of both, whendetecting positive expression of at least FOXM1; PTTG1; and ZNF367 atlevels, when combined, that are the same or higher when compared to thelevels of expression from the sample assayed prior to receiving theneoadjuvant or the adjuvant therapy, or combination of both; or changingthe neoadjuvant or the adjuvant therapy, or the combination of both,when detecting positive expression of at least FOXM1; PTTG1; and ZNF367at levels, when combined, that are the same or higher when compared tothe levels of expression from the sample assayed prior to receiving theneoadjuvant or the adjuvant therapy, or combination of both.
 35. Themethod according to claim 34, wherein the neoadjuvant therapy andadjuvant therapy is an agent selected from the group consisting of:trastuzumab, lapatinib, neratinib, afatinib, pertuzumab, CDK4/6inhibitors, cyclophosphamide, methotrexate, 5-fluorouracil, gemcitabine,adriamycin (doxorubicin), epirubucin, docetaxel, paclitaxel,capecitabine, and tamoxifen.
 36. The method according to claim 34, themethod further comprising the step of assaying for the expression ofp16^(INK4A) gene or a protein encoded by said gene.
 37. The methodaccording to claim 34, further comprising assaying the cancer samplefrom the patient for positive expression of UHRF1, MYBL2, E2F8, HMGB2,ATAD2, E2F1, or TCF19.
 38. The method according to claim 34, wherein thecancer is selected from the group consisting of: node-negative,ER-positive breast cancer; early stage, node positive breast cancer;multiple myeloma, prostate cancer, glioblastoma, lymphoma, fibrosarcoma;myxosarcoma; liposarcoma; chondrosarcoma; osteogenic sarcoma; chordoma;angiosarcoma; endotheliosarcoma; lymphangiosarcoma;lymphangioendotheliosarcoma; synovioma; mesothelioma; Ewing's tumour;leiomyosarcoma; rhabdomyosarcoma; colon carcinoma; pancreatic cancer;breast cancer; ovarian cancer; squamous cell carcinoma; basal cellcarcinoma; adenocarcinoma; sweat gland carcinoma; sebaceous glandcarcinoma; papillary carcinoma; papillary adenocarcinomas;cystadenocarcinoma; medullary carcinoma; bronchogenic carcinoma; renalcell carcinoma; hepatoma; bile duct carcinoma; choriocarcinoma;seminoma; embryonal carcinoma; Wilms' tumour; cervical cancer; uterinecancer; testicular tumour; lung carcinoma; small cell lung carcinoma;bladder carcinoma; epithelial carcinoma; glioma; astrocytoma;medulloblastoma; craniopharyngioma; ependymoma; pinealoma;hemangioblastoma; acoustic neuroma; oligodendroglioma; meningioma;melanoma; retinoblastoma; and leukemias.